ChallengeThe majority of care home residents are living with complex co-morbidities and as those residents age, their health needs inevitably increase.
We have seen an increasing number of emergency hospital admissions from care homes for conditions such as urinary tract infections, pneumonia, respiratory infections, fractures of femur, chronic obstructive pulmonary disease and heart failure, resulting in extended stays in hospital, putting additional pressure on Secondary Care that could potentially be averted with earlier identification and intervention. Evidence also shows that for older people in particular, longer stays in hospital can lead to worse health outcomes and can increase their long-term care needs
Meanwhile, there are a number of challenges currently facing the Care Home Sector including:
• Sustainability of the market in particular nursing bed provision
• Variation in quality of care
• Staff turnover
• Duplication and fragmentation of staff training
• Avoidable hospital admissions from care homes
- To improve the sustainability of the market in particular nursing bed provision
- To improve the quality of care across the nursing home sector reducing variations in the care provided
- To reduce staff turnover
- To reduce duplication and fragmentation of staff training and to bring all homes up to acceptable standards
- To reduce avoidable hospital admissions from care homes
To help address these issues and to support the care homes to offer better support to their residents, a number of initiatives have been commissioned jointly with the Local Authorities using targeted funding sources such as the Better Care Fund. In addition, where opportunities presented, existing services have been redesigned to offer more focused support to the care homes. Some of the services now on offer across local authorities (not all services operate across each) include;
Care Home Training and Education Programme (Stockton and Hartlepool), commenced February 2017
Delivered through a training alliance co-ordinated by the Education and Organisation Development department within North Tees and Hartlepool NHS Foundation Trust.
Partners include; North Tees & Hartlepool NHS Foundation Trust; Tees, Esk & Wear Valleys NHS Foundation Trust; Hartlepool Borough Council, Stockton Borough Council and Alice House Hospice, working together to deliver a four-pronged package of training focusing on the wellbeing of frail elderly residents, falls prevention, dementia awareness and end of life care.
Aims to improve the knowledge and confidence to both registered and non-registered care home staff to make informed decisions that would result in a reduction in avoidable admissions to hospitals whilst improving the quality of care delivered.
The support offered through this programme also includes the roll out and use of the National Early Warning System (NEWS). These are digital tablets which provide a standardised means of identifying and responding to deteriorating or acutely ill patients in the community and in-hospital settings capture electronically to help to proactively manage peoples care.
The NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in hospital. Six simple physiological parameters form the basis of the scoring system:
- respiration rate
- oxygen saturation
- systolic blood pressure
- pulse rate
- level of consciousness or new confusion
The score is used to inform clinicians (GPs, Community Matrons etc) as to whether the resident is becoming seriously ill and allows them to take appropriate action, such as calling for specialist help, if necessary. The system has also received positive feedback from other associated clinical professionals including the 111 staff.
Trusted Assessors (to be available in all localities), commenced November 2018
Trusted Assessors act on behalf of the care home manager to pull together clinically relevant, accurate and detailed information of hospital inpatients who require long term care in order for a care home placement to be made. The Trusted Assessor removes the need for the care home manger to attend the hospital to complete the care assessment should they feel the need to do so.
Community Matrons will absorb this function into their existing roles during the trial period. As this develops the Trusted Assessor role will expand into the Hartlepool and possibly Darlington areas.
Red Bag Scheme (Available in all localities), commenced October 2018
This scheme is now underway.The bags, when used travel with patients to and from hospital where they are handed to the ambulance and acute service provider staff.
The bags will contain individual patients key paperwork, medication and personal items like glasses, slippers and dentures.The Red Bag also clearly identifies a patient as being a care home resident and
the information contained in the bag allows for better transfers of information, to give all involved an immediate understanding of the residents current and future care needs.
Pharmacy support (specific additional commissioned service in Hartlepool, commenced January 2016. Generic Meds Team support across all localities).
The Meds Team are working with homes in Hartlepool through the additional commissioned service, to offer targeted support to improve the skill of the staff in the care homes in relation to the administration, storage and use of medication.
All three local authorities are currently supported though the generic NECS Meds Team service which offers general advice and guidance but not specific targeted one to one support. The localities will also benefit in the near future from the new NHSE funded initiative, Medicines Optimisation in Care Homes service which will be undertaking medication reviews on all new residents who are admitted.
React to Red (All localities), NHSE funded/ initiative
This is a pressure ulcer prevention campaign that is committed to educating as many people as possible about the dangers of pressure ulcers and the simple steps that can be taken to avoid them. All homes have been offered general advice and guidance on this issue which is reinforced through the training alliance work.
Community Matron Service (All localities), Core contract, commenced August 2016
Community Matrons currently work within existing general practice (GP) clusters defined by Teams Around the Practices (TAPs) and are aligned to individual care homes across the locality. They manage patients identified with the highest risk across the cluster, assessing and implementing appropriate management plans under a shared care arrangement with patients GP. The Community Matron is responsible for developing in conjunction with the GP and the resident, an appropriate holistic management plan, identifying and addressing any specific need, co-ordinating input from other services where appropriate, providing education around self-management and when and how to best access appropriate services. The Community Matron is also responsible for communicating the agreed management plan to the GP and GP practice.
Enhanced Primary Care Support Scheme (Darlington Care Homes only), commenced June 2018)
The remit of the service aims to address the specific additional primary healthcare needs of residents living in nursing and residential care homes, recognising the benefits of working in partnership with the home, acute and community services, and the noting the additional input required from General Practice to ensure the highest quality of care and to avoid unnecessary hospital admissions.
Falls Prevention in Care Homes (Stockton locality only), commenced 2016
The aim of this scheme is to provide people deemed as ‘high falls risk’ access to bed and chair sensors.
Care Home Web Live Portal – Capacity Tracker (All localities,) commenced April 2018
A free simple web based application aims to enable bed state communication between Care Homes, CCGs, LAs and Trusts based upon real-time information to allow stakeholders to easily identify care home vacancy information improve patient flow and facilitates more efficient and informed transfers of care.
The portal is available nationally to all local authorities and was formally adopted by the Darlington, Hartlepool and Stockton on Tees localities in April of this year. An ongoing programme of implementation and awareness is currently being undertaken with the Local Authorities and other strategic partners.
Although some of these programmes are fairly new initiatives, there are already signs of improvement and measurable reductions in the numbers of A&E attendances and non-elective admissions. Other individual scheme impacts include;
Care Home Training and Education Programme:
In the first two years 2,433 staff attended the training with 427 sessions delivered
Red Bag Scheme:
Care Home and NHS staff are reporting more positive transfers of care through the provision of more timely and up to date information.
- Significant reductions in CQC issues and safeguarding alerts due to medication
- 16/17 £91,000 of medicines waste identified, £68,000 achieved and evidenced
- 17/18 £46,000 of medicines waste identified, £16,000 achieved and evidenced
Working proactively with homes to manage the care of residents so that they receive more appropriate and personalised care. Community Matrons are also utilising and have access the NEWS Scores collected as part of the Training and Education programme. The Community Matrons have developed excellent relationships with the care home staff.
Care Home Capacity Tracker
The system offer real time Care Home vacancy information across the adult residential and nursing care home sector. It is now being adopted by an increasing number of local authorities and CCG nationally and is developing to offer a range of information and intelligence about the Care Home Sector.
The national usage picture at 21 May 2019 is as follows:
- Care Homes registered: 6791
- Users registered: 10,458
- CCGs represented: 191
- LAs represented: 149
Work is ongoing with providers to implement the system across the in Darlington, Stockton on Tees and Hartlepool with only 5 homes in total having not yet accessed the system.
The programme of ongoing promotion of the system continues in partnership with the Local Authorities. The emerging national picture is that the tracker is supporting a reduction in DToCs as a result of capacity information being available to support families and professionals in identifying the most appropriate care for their family members.
Overall reduction in NEL (16/17 to 17/18):
Reduction in emergency admissions from Hartlepool and Stockton Care Homes: 9% (2191 – 2000)
Cost savings from the reduction: £686,836 (£3596 x 191)