Transcript Slide 1

Older People Residential &
Nursing Provider Forum
Sovereign Harbour Yacht Club
3 Harbour Quay, Eastbourne
18.09.12
Ann Barrett
Occupational Therapist
Team Lead - East Sussex Care & Nursing Home Support Services
Julie Sands
Advanced Community Nurse Practitioner
Robin Warshafsky
GP, Urgent Care Lead, High Weald CCG
Associate Medical Director, South East Health
Ann Barrett
ESCANS (East Sussex Care & Nursing Home Support Service)
Julie Sands
Presentation to raise awareness of Community Matron Role and recognise
the signs of deterioration in residents
Admission avoidance and a reduction in GP visits to a local care home – is
it achievable?
Robin Warshafsky
Guidance on obtaining a doctor’s advice out of hours
Care Home referral form to out of hours
Collaboration between NHS resourced clinical support and Care Home Sector
PURPOSE
Improve quality of care to residents by:
Offering education & tools to care home staff for better care & decision making
Offering to review care of residents to ensure meeting goals of management plans
Offering to assist in review of medication management
Offering to assist in end of life care goals and advance care planning
WHY?
Maintaining high quality care for care home residents is everyone’s business:
Residents, Families, NHS, Care Home Sector, Society
No one group can achieve on their own
Becoming larger issue, see demographics, next slides
Excellent way to promote the care you offer to prospective clients / residents and
their family members
2011 CENSUS 65+
England &
Wales
South East
East Sussex
Eastbourne
Hastings
Lewes
Rother
Wealden
16.4
17.2
22.7
22.4
16.9
22.8
28.4
22.8
SECULAR TREND 65+
2010 2015 2020 2025
England
16.5 18.0 18.7 19.9
South-East 17.2 19.2 20.4 21.8
East Sussex 23.5 26.0 27.4 29.2
Eastbourne 23.3 24.9 26.3 28.0
Hastings
17.6 19.7 21.1 22.6
Lewes
23.7 25.7 26.9 28.8
Rother
28.5 31.4 33.1 35.0
Wealden
23.4 26.9 26.9 30.7
EAST SUSSEX 85+ SECULAR TREND
2011
2015
2020
2025
19, 900 23, 600 25, 600 30, 000
2030
2035
36, 600 46, 600
2030
21.4
23.9
31.9
30.4
24.9
31.3
38.0
33.5
2035
22.9
25.6
34.2
32.4
27.0
33.5
40.5
35.8
17% increase in deaths from 2012
40% of deaths in hospital could have occurred elsewhere
East Sussex: hospital 49.0%
60% people do not die where they choose
East Sussex: home 17.6% hospice 6.8% care home 24.1%
75% deaths are from non-cancer conditions
85% of deaths occur in people over 65
£19,000 non cancer, £14,000 cancer - average cost/patient in final
year of life
www.endoflifecare-intelligence.org.uk
www.goldstandardsframework.org.uk
Maintain & enhance the quality of health care for the residents of Care Homes
in association with pharmacy and nursing staff providing health care cover to
each Home, so offering consistency, efficiency and a higher quality of service.
Expectation: this will offer alternatives to admissions to acute hospitals and
help make more informed decisions regarding use of Out of Hours services by
Care Home staff.
Evidence  patients in Care Homes have higher needs than other patients for
essential medical cover  medical needs are complex and changeable
Require visits to Care Home, frequent & multiple prescribing interventions &
they have a higher than average use of Out of Hours Services.
from generic Care Home Enhanced Service Specification document
“We looked at how to take a collaborative approach
to support care home staff with a package of regular
training, a care plan for patients, and a nurse
specialist who could work alongside them and
support them with advice and guidance.”
Gateshead Clinical Commissioning Group
WALES 2008-2009 Enhanced Service for Care Homes
Provide patients with 6 monthly medication reviews thus ensuring that
prescribing is appropriate for the patient minimising risk to the patient
Build effective communication links between Primary Health Care Teams
& nursing and residential care staff
Ensure, where appropriate, that patients have the opportunity to record
their EoLC plans and to ensure such plans are available when required
Reduce inappropriate admissions
Improve this vulnerable group’s overall health by providing a more
holistic service
Barking & Dagenham 2008 Enhanced Care Home Service
A dedicated weekly session per nursing home including visits;
A more comprehensive assessment of all new admissions;
A yearly assessment of all residents;
Demonstrably increased availability via telephone for medical advice
and triage
Lead responsibility for assigning appropriate aspects of service
provision to other care professionals; e.g. medicine management and
pharmacist support or preventative work carried out by nursing or
health care assistants
Better acquisition, documentation & sharing of essential
information about the resident to inform decisions
“The assessment information will be recorded in the patient’s
record and the care plan will be held at the care home to assist
in the management of the patient and be available to
practitioners out of hours.”
“work with nursing home staff and patients, where the clinician
feels it is appropriate, to develop end of life care plans with
patients and their relatives. Such plans will be held both in the
patient’s notes and by the care home staff and must be available
when required. These plans will be available at the care home and
can be accessed out of hours along with the care plan.”
In Words
Resident
”I only see him once a week when he comes to do the rounds – he is a very nice young
man and he is very good. He understands you and wants the best for you and listens to
what you say. I’ve been here a year and seen another student doctor but have had no
problems with either. Sometimes he is on holiday but it doesn’t matter. He always
orders the prescriptions monthly or something and they are sent over automatically – he
is very [conscientious].”
‘
Care Home Manager
“Two years before, a number of different GPs visited the home and referral processes
took longer. Now the whole service has been brought together and it is quicker. It really
has been amazing for us: good for relationships between GPs and next of kin or friends,
and has cut down referrals to hospital. Having someone come in and refer to clients
personally has made a difference.”
Briggs, D & Bright, L. Reducing hospital admissions from care homes: considering the role of a local enhanced service
from GPs Working with Older People Volume 15 Issue 1 March 2011
By Numbers
“aims … were achieved   43% in emergency admissions
 45% reduction in deaths in hospital
“Improved anticipatory planning and increased medical and
nursing support for patients and staff in residential homes may
help to further reduce emergency admissions and deaths in
hospital in future.”
Evans, G. Factors influencing emergency hospital admissions from nursing and residential homes: positive results
from a practice-based audit. J Eval Clin Pract 2011 Dec; 17(6) :1045-9.
Julie Sands
Advanced Community Nurse Practitioner (ANCP)
(Formerly Community Matron, CM)
74yr old lady
H/O arthritis
Hypertension
“Breathlessness”!
Recent bereavement
Ex smoker 2 weeks!
Recurrent chest infections
BP 180/80 P68 reg R19 sats 93%
Bilateral ankle oedema to calf.
BMI 35
PF diary ranged from 150 – 220
Post ausc – good air entry with fine crackles to left
mid, lower and aux zones, right lower and aux zones.
Ant ausc – unable to due to size
Poor mobility due to arthritic pain
Random BM 13.3mmols
Ask PN for spirometry
Check bloods for Hbalc
Discuss meds with GP for BP, pain and chest following
spirometry
Advice re diet
Spirometry - FEV in 1 sec, 0.82 litres.min 58%
- FVC 1.42 litres/min 81%
= mild COPD
oHbA1c – IFCC standardised 55 mmols/mol (7.2%)
Introduce Seretide inhaler
Introduce tiotropium inhaler
Introduce ACE (Ramipril)
Increase/change dieuretics
Monitor diet for diabetic control and weight loss
Increase analgeisa for pain and mobility
Review bloods 3 months for diabetic control
BP 148/80mm hg P80 R 16 sats 93% (Nail varnish)
Bilateral ankle oedema reduced.
Chest – still some crackles present
Patient more cheerful
GP visits reduced
Less interventions by MDT
Pre intervention
Planning
Post intervention
Total visits
Feb
March
April
GP
5 visit
1 telephone
2visits
2 phone
1 PN visit
1 visits
1 telephone
DN
1 visit
0 visits
1 visit
CM (ACNP)
0 visits
4 Visits
1 visit
Total interventions
7
9
4
Last intervention by ACNP on 27/4/12
No interventions in
May so far!
East Sussex Care & Nursing Home Support Service
(ESCANS)
CQC enforcement action taken in 2012 against the owners
of the home to protect residents living at the home
CQC - 0/5 standards met at beginning of intervention
ESCANS contacted by Adult Social Care (ASC) Safeguarding
department – Level 4 SAAR in place. Home suspended by
ASC
Initial meeting set up with new manager following working
day after ASC agreed ESCANS could approach the home
Staffing – high turnover/currently recruiting new staff
Care planning – generic in nature and not client centred
Knowledge base – Limited knowledge of staff around falls and
general health awareness
RIDDOR reporting – unclear what needs reporting
Maintenance checks – To be established
Owner support - unknown
Management – currently on 3rd manager in 6 months. Impact
on morale and trust for care staff
CQC report – impact on staff morale and unknown future of
home
Provide falls awareness training to the home
Complete Environmental review
Referred to Dementia In-reach team for support
Meeting agreed with Environmental Health to discuss
RIDDOR reporting
Train staff in mobility aid and wheelchair safety and how
to complete regular checks
Provide support/advice for onward referrals to community
service for residents
Case work scenario of 1 resident
New staff employed and keen to promote change in
culture – evident during training sessions
Care plans – rewritten “include detailed information
about the needs of people and how they were to be met”
CQC July 2012 p11
Knowledge base – “There was evidence that since the
September 2011 inspection, staff had undertaken a
substantial amount of training. This included challenging
behaviour, falls awareness” CQC July 2012 p22
CQC visited and now meeting 5/5 standards
Safeguarding restrictions lifted by ASC and now open
to new admissions
Admissions decreased since ESCANS input
ESCANS asked to support sister home locally
GUIDANCE ON OBTAINING DOCTOR’S ADVICE OUT OF HOURS
The goal is to avoid causing unnecessary distress or harm to the patient.
Admitting an elderly patient to hospital is often not in their best interests.
We hope you will consider
the request for doctor’s advice out of hours, carefully.
Is the patient presenting with NEW or WORSENING symptoms?
Does their condition require URGENT medical care?
There are three possible degrees of urgency as described below.
For the best outcome for the patient, and avoid overtreatment by doctors unfamiliar with the patient, which of the three possibilities is most appropriate.
Situation Two
Situation One
Contact normal hours GP
There is a new symptom or worsening of an
ongoing problem that could wait for advice from
the surgery the next day.
If Friday or Saturdays will it wait one or two days.
For example:
• Cough, without fever, shortness of breath,
confusion, change in behaviour or appetite
• Signs of urinary tract infection without fever,
severe discomfort, visible blood in urine
• New onset confusion where there is no
change in level of consciousness or onset of
difficult behaviours
• Constipation without significant discomfort
or changes in behaviours
• Skin problem/infection without fever or
significant discomfort
• Fall with no apparent injury
Contact OOH GP
There is a new symptom or
worsening of an ongoing problem
that warrants urgent assessment by
the duty doctor during the period
1830-0800 weekdays or on weekends.
For example:
• Cough with shortness of breath,
fever, or significant discomfort
• Signs/symptoms of UTI with fever,
significant change in behaviour
• Other infection with fever, but
patient’s level of consciousness and
functional ability not compromised
• Fall with minor injury or uncertain
about degree of urgency
Situation Three
Dial 999
There is a new symptom or worsening of a
ongoing problem that warrants emergency
treatment
For example:
• Chest pain: especially if dull, heavy,
pressure like
• Shortness of breath that is severe: patient
cannot speak, turning blue, heaving chest
• Severe abdominal pain: patient restless and
distressed
• Definite stroke: obvious weakness of
face/arm/leg, incomprehensible speech
• Blood loss: heavy blood loss from
nose/mouth/vagina/anus
• Fall where there is severe pain, head injury,
loss of consciousness, unable to move or
weight-bear
•Does the patient have a DNACPR or ADRT
that precludes hospitalisation or aggressive
medical intervention in any circumstances.
For situations 2 & 3, complete the Care Home/Nursing Home pro-forma.
The assessing doctor, either on the phone, a visit or in A&E, will hopefully have
an assessment with information to avoid overtreatment/admission.
POSSIBLE TOPICS FOR STARTERS
Respiratory conditions
Cellulitis
UTI/Elimination
Falls, soft tissue injuries, fractures
Collapse, loss of consciousness
Confusion
Mobility
Nutrition
Etc, etc
Previously discussed with Kay Muir EOLC Lead:
Advance Care Plan, DNACPR
NEXT STEPS?
Where do we go from here?
Working group:
Care Home representatives + Clinicians + PCT/CCG support
+ ESCC representation- Quality Review Nurse role?