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Enhanced health in care homes framework (Introduction (aim: improve…
Enhanced health in care homes framework
wider context
Primary goal H & SC
support people in their own home for as long as possible
If nolonger possible, ensure best possible care provided to those in residential settings/ those at risk of losing their independence.
3 barriers to good care
Care
A narrow focus on medical rather than holistic needs
Lack of integrated care planning that focuses on prevention and pro-active care
Variable access for care home residents to NHS services
Lack of continuity of care and the difficulties faced by the current workforce crisis
Financial
Few system-wide incentives around preventative care across health and social care providers
A financially distressed care provider market which will impact on quality in some care
homes
The financial challenges that the national living wage and other centrally imposed cost increases put on the finances of the providers and local authority/ clinical commissioning group commissioners
Recruitment and retention (including training) within the care sector
Contractual mechanisms for provision of preventative health care for those in care
homes and those at risk of losing their independence
Organisational
Barriers between organisations in different parts of the health service and between the
NHS and other sectors, in particular social care
A lack of financial and clinical accountability for the health of the defined population
Variations in policy, process and supporting systems (such as information technology (IT))
across organisations
This model plans to overcome these challenges by
people have access to enhanced primary care and to specialist services;
budgets and incentives are aligned so that all parts of the system are unequivocally focussed
on improving people’s health and wellbeing;
the working environment is optimised for staff employed by social care providers so that they feel at the heart of an integrated team that spans primrary, community, mental health and specialist care, social care services and voluntary sector
people maintain their independence as far as possible by reducing, delaying or preventing the need for formal social care services
health and social care services are commissioned in a coordinated manner, and the role of the social care provider market is properly understood by commmissioners and providers across health and social care.
Applies to self-funders and funded by NHS/LA.
footprint - all care homes (residential and nursing) in plannig footprint for the EHCH model; STP/ICS, CCG, LA, MCP, PACS. Scope can include reablement and rehabilitation services (in community) avoiding unneccessary admissions to AE or care homes
Draws on 'I statements' (Think Local Act Personal-TLAP partnership spannng H and SC sector + 'My Home Life' initiative (promotes qty of life and positive change in care homes).
A range of 'small big ideas' - simple ideas that done well and replicated elsewhere - may not solve big problems but improve quality and outcomes of care for care home residents. Frugal innovations - simple and replicable.
Introduction
aim: improve quality of life, healthcare and planning for people living in care homes. Optimise health of residents.
1in 7 = or > 85 lives permanently in a care home.
Evidnece: they're not having their needs properly assessed and addressed
thus experience avoidable admissions to hospital and sub-optimal medication.
6 vanguards: care homes working with NHS, LA, voluntary sector, carers, families
= new care model, will become core element of multispeciality community provider (MCP) and primary and acute care system (PACS) models.
= a suite of evidence-based interventions, many elements of which are already established across the country.
6 vanguards
Gateshead Care Home Project
Airedale and Partners
Nottingham City Clinical Commissioning Group
Connecting Care Wakefield District
Sutton Homes of Care
Linked GPs carry out health and wellbeing reviews of residents in 6 nursing homes across the borough, so residents have individual care plans developed in partenrship with them, family, GP and home care coordinator - to ensure provision of preventative/ proactive holistic care. Includes nutrition and hydration cards developed for care home staff.
East and North Hertfordshire Clinical Commissioning Group
Key messages
shared coordinated approach to care delivery ensures access to best care possible.
comprehensive Geriatric Assessment (CGA) is vital part of personalised care planning
Strong personal relationships between care home providers and GP ractices critical to developing local enhanced primary care support.
Continuity of care matters to individuals/ carers/ families.
carers/ families should be supported in making care decisions.
Care elements and sub-elements
enhanced primary care support
MDT support including coordinated health and social care
Reablement and rehabilitation
High quality end of life care and dementia care
Joined-up commissioning and collaboration between health and social care
workforce development
Data, IT and technology
Linked health and social care data sets
Access to the care record and secure email
Better use of technology in care homes