Transcript Nursing & Care Homes Support – East Sussex

Nursing & Care Homes
Support – East Sussex
Sophie Clark, Older Peoples Strategic
Commissioner, ESCC ASC
Kay Muir, Programme Lead, End of Life Care,
NHS East Sussex
Services Supporting Nursing &
Care Homes
Dementia
Support
Team
End of Life
Care Team
Adult Social
Care
E. Sussex
Care &
Nursing
Homes team
Medicines
Management
Support
Quality
Monitoring
Team
Dietician
Work already underway
• End of life care and dementia teams fully
established
• Care & nursing home support team
recently in place
• Large overlap in ‘priority homes’ lists
between services, with some differences
reflecting profile of need for specialist
services e.g. dementia care
Working together
• Services need coordination to ensure
maximum impact, avoid duplication etc.
• Steering group established to:
– Agree priorities and overall workplan
– Record activity done with each home
– Share information and develop a holistic
package of support for each home
Working model
• Initial visit to home by one or other team to
assess support needs
• Agree improvement plan with home
• Coordinated approach between teams to
cover nursing & care competencies, falls
prevention, medicines, end of life care,
dementia etc as needed
• Initial focus on homes in highest need
Team Composition
Team
Provider
Composition
Contacts
End of Life Care
St Michaels Hospice
St Wilfrid Hospice
Specialist palliative care nurse
Consultant input as required
Trainers
Jo Barnes
Carolyn Skilton
Kay Muir (End of Life Care –
PCT)
Dementia Team
Sussex Partnership
Trust
0.5 x Psychiatrist
0.5 x Pharmacist
3 x Community Psychiatric
nurse
1 x Occupational Therapist
Stephanie Giles
Nigel Blake-Hussey (PCT /
ESCC)
East Sussex Care &
Nursing Home Support
Team
ESHT
1 x Physiotherapist
1 x Occupational Therapist
1 x Dietician
0.3 x pharmacist
1 x B3 admin
1 x Community Matron – TBA
1 x B6 Physio - TBA
Michelle Connelle
Adult Social Care
East Sussex County
Council
Safeguarding teams
Paul Maynard
Sophie Clark (Older People’s
Commissioning)
Quality Monitoring Team
East Sussex County
Council
Contracting staff
Malcolm Price
What else is needed?
• Confirm availability of Community Matron
resource (current nursing skills gap)
• Develop mechanism to accept referrals
• From A&E and hospital staff
• From GPs
• Develop links to CCGs
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Getting access to local knowledge
Medical cover if needed
Following up recommendations e.g. drug changes
Help get access to and ‘performance manage’
homes
Outputs to follow
• Combined quarterly reports from all teams
– Activity, impact on quality, safety, costs
• Outcome data on hospital admissions, 999
calls, fractures etc
• Feedback from homes, patients,
stakeholders
• Evaluate impact and develop business
case for future funding (Feb 12)
Aim of EOLC provision
To pump prime services for 1 year to support Care
Home staff to provide good quality EOLC to meet the
resident and family needs.
In addition to significantly contribute to:
• the whole system reduction in End of Life Care
(EOLC)
• emergency hospital admissions and deaths
End of Life Care Provision for the Care
Home Support Team
EOLC staff support:
• Eastbourne and surrounding area - St Wilfrids Hospice
• Hastings and Rother area
- St Michaels
Approach taken:
Use of EOLC emergency admission data and urgent care data on Care
Home resident attendances at hospital
Multi-disciplinary approach with support Hospice Medics and training
department, GP liaison, ESCC Quality Monitoring team, wider Care
Home project linked to Urgent Care
Initial contact made to the senior management of the care home by the
SPC nurse combined with a joint letter of support to Care Home from the
PCT and ASC
Meeting national EOLC
competencies and standards
ESCC Care Home Contract
• “That the Service Provider and their staff should ensure they are
familiar with the principles and best practice guidance set out within
the national End of Life Care and East Sussex End of Life Care
Strategies, and apply the principles and good practice of the Gold
Standards Framework for Palliative Care.”
• “The Service Provider should ensure that staff have access to and are
encouraged and supported to use nationally recognised end of life
care tools such as:
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Advance Care Planning
Preferred Priorities of Care
Liverpool Care Pathway for the last few weeks/days of life
NHS South East Coast Do Not Attempt Cardiopulmonary
Resuscitation (DNACPR) principles”
EOLC project reporting - 1
1.
Baseline audit: After Death Analysis and Routes to Success Care
Home questionnaire
2.
Documentation of managerial and staff commitment to adopt national
standards and competencies
3.
Documentation recording what the status is of the Care Home
provision along each stage of the EOLC pathway at baseline, interim
report and final report using the Routes to Success template
4.
To have a written action plan with clear priorities to target in relation
to quality and emergency admission avoidance for each home.
Reporting - 2
6. Training record by subject and uptake for each care home involved
with.
7. Recording of emergency admissions to hospital each month and
reason why and if these could have been prevented
8. Ongoing ADA with subsequent deaths in the home during the pilot
period, actions required to improve the quality of care identified and
shared with Care Home manager and staff
9. Proactive actions taken to reduce avoidable admissions as a result
of the project
10. Interim report being presented to the PCT Commissioning Clinical
Executive view to extend project by 1 year funding permitted