Transcript Complex Care Premium

East and North Hertfordshire:
Care Home Improvement vanguard
Claire Jackson, Clinical Quality Manager,
ENHCCG
Michelle Airey, Recruitment & Logistics
Manager, HCPA
East and North Hertfordshire
Our Vision:
“To deliver an enhanced model of health and
social care to support frail elderly patients, and
those with multiple complex long term conditions
in the community in a planned, proactive and
preventative way”
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Complex Care Premium
Patient presents with Complex Characteristics
Referral
Accredited
Care Home
Top up
Payment
Quality care
for complex
patients
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CCP Team
East and North Hertfordshire
Inputs
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Expectation Setting Session
5 x Qualified Advanced Champions – Training
AET L3
Subject Specific Qualification
Preparing for a Coaching Role L4
1 x Mentored Engagement Advanced Champion – Training
Engagement Practice in a Care Setting L3
Individual Exercise Plans
1 x Manager - Training
6 months of Beyond the Armchair
Pre- Evaluation
Preparing CCP Team Support Meeting x 2 per home minimum
East and North Hertfordshire
Outputs
• 5 x Qualified Advanced Champions Cascading Knowledge and Skills to staff
through mentoring, coaching and training
• 1 x Mentored Engagement Advanced Champion mentoring Knowledge and
Skills to staff
• 1 x Manager Setting Strategies
• Reviewed Activity Plans and Recording Procedures for Engagement
• Individualised Falls Risk Report
• Engagement Lead delivering 1:1 tailored exercises
• IFS Report and Action Plan
• Post Evaluation Action Plans for each pathway and overall
• Monthly Data Collection Report
• Action Planning for each pathway
• Certificates
• Badges & Marketing Materials
• Display Board
East and North Hertfordshire
Care homes in the wider health system
Key Milestones for delivery
The key milestones for delivery will be:
1. Confident Staff
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Homes receive Complex Care training and receive
top-up premium
All homes receive enhanced dementia and End of Life
training
2. Multi-Disciplinary Team
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Enhanced Primary Care support implemented
Care Homes Medicines management team in place
Interface geriatrician team in place covering all homes
Homefirst enhanced community teams in place
Specialist end of life nursing team in place
3. Rapid Response
• Community rapid response teams (Homefirst) in place
• Rapid response vehicles operational
4. Information, data and technology
• Primary care data fed into MedeAnalytics to deliver
Care Home performance dashboard
• Telemedicine rolled-out
• Primary care data extracted and fed into risk
stratification model
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CCP Case Study
While Burleigh House already had strong
links with local GP surgeries and Lister
Hospital the introduction of dedicated GPs
for each care home and regular visits from
community pharmacists to review patients’
medications is proving very worthwhile.
Ian, 61, has been a resident at Burleigh
House for less than a year. He suffers from
Epilepsy and has complex care needs
following a fall at home. He initially came
to Burleigh House for respite care, but liked
it so much he asked if he could stay.
“Training gained through the
Complex Care Premium allows
us to act more effectively as a
preventative source. With their
new training staff can identify
potential risks earlier and flag
them up with doctors and
prevent residents’ conditions
worsening.”
Staff are keeping on top of his medication
and are able to support him when he has a
crisis, rather than always calling an
ambulance to take him to hospital.
Both Peter and Mihir agree that the care
homes ‘vanguard’ project fits with the
home’s ethos of managing the health and
wellbeing of their residents to give them a
better quality of life.
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Outcomes
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CCP Team Meeting & Case Notes Weekly/Monthly
Reviewed Staff Training Plan reflecting CCP Training
Stronger senior team
Lower Hospital Admissions
Lower Ambulance Call outs
Improved Service User Experience, personalised, focussed on wellbeing
Improved Family Communication/Involvement
Improved communication with clinical professionals and better management of health issues
Fewer behaviours that may challenge – less reliant on CAT and less anti-psychotic medication
Better Weight Management & Hydration & Reduction in Supplements
Fewer Falls, improved stamina, increased flexibility, improved muscle strength
Prevention and/or better management of wounds
End of Life audits
Confident staff teams
Service Users being managed under ‘Best Ability to Function’ guidelines
Good/Outstanding Monitoring Reports
Continue onto CC-CPDF
East and North Hertfordshire
As a result of our project we would expect to see:
Fewer
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• Staff, residents and families
reporting feeling satisfied with care
• People dying in their preferred
place of death
• Calls to NHS 111
• People living healthier lives for
longer in care homes
• Care home staff choosing to stay
longer in their jobs
999 calls
A&E attendances
Emergency admissions to hospital
Short stays in hospital
Calls to the out of hours GP
service from care homes
• ‘Delayed transfers of care’
Progress to Date
• Complex Care Premium developed and established
• Training delivered and commenced to 20 homes (12 in E&N
CCG area) – collecting data from Oct 15
• 10 further care homes identified for phase 2
• Complex Care Foundation and application to home care?
• Project Group established, a variety of initiatives
underway:
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Care home pathways review
Medicines optimisation
Frailty Vehicle
Enhanced primary care support
End of life care
Telecare
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