Health and Social Care Integration- Ageing Well and Digital Programme Skills for Care event, 23 May 2019 Tom Luckraft and Pallavi Kaushal NHS England NHS England and NHS Improvement
Agenda 1.Quick guides 2.Long Term Plan- Ageing well programme 3.NHSmail for Social care providers 4.Interactive discussion 5.Concept testing NHSmail communications 2 2 | | Presentation title
Quick guides A suite of published Quick Guides can be found at www.nhs.uk/quickguides. Rapid Improvement guide: Trusted Assessor resources • Improving hospital discharge • Discharge to assess • Improving hospital discharge to care sector • Supporting patients’ choices to avoid long hospital stays – Patient leaflet, easy-read and policy document • Sharing patient information • Better use of care at home • Health and housing • Better use of care at home • Sharing patient information • Enhancing health in care homes • Quick Guide: Hospital Transfer Pathway – ‘Red Bag’ • Identifying local care home placements • Technology in care homes • Managing care home closures – Management checklist, stakeholder duties and powers • Clinical input to care homes • Sharing patient information 3 3 | | Presentation title
NHS Long term Plan • NHS Long term plan shows how the NHS is going to be using its new funding of an extra £4.5 billion a year in real terms by 2023/24 to improve staffing and expand needed services. • The Ageing well element of the NHS Long term plan focusses on addressing the concerns about funding, staffing, increasing inequalities and pressures from a growing and ageing population. 4 | 4 |
What is policy seeking to achieve for older people? Key outcomes: 1) Care that makes sense to people (and their carers and families) 2) People get what they need, when they need it. 5 | 5 |
Three national priorities for older people 1. Change in approach to health & social care nationally 2. Preventing poor outcomes through active ageing 3. Quality improvement in existing acute & community services 6 | 6 |
Words matter: be careful using the F-word • Elderly =adjective: advanced age, old • Frail =adjective: easily broken, not robust, weak • Frailty = noun: the quality or state of being frail [ and not exclusively biomedical ] • Older : adjective: comparator of old • Ageing =verb: to grow old a normal phenomenon The frail elderly = not robust & old: ‘an inevitable end state for everyone ’ People with frailty = people with specific needs + preferences Ageing well = growing old positively: many can achieve this 7 | 7 |
What’s the national approach? FROM THIS TO THIS ‘An Older Person ‘ The frail Elderly’ living with frailty’ A long-term condition Frailty is Timely Late being identification used here Crisis presentation preventative, proactive care as a supported self management paradigm Fall, delirium, immobility & personalised care planning Community based Hospital-based person centred & episodic care coordinated Health + Social +Voluntary+ Disruptive & disjointed Mental Health + Community assets 8 | 8 |
System challenges & opportunities • People with varying degrees of frailty don’t always get the care they need in the right setting and at the right time- Source: People first, manage what matter, Newton Europe, 2019 • Hospital interventions for some people with frailty are limited in efficacy • National audit data (NAIC 2017) suggests intermediate care capacity needs to increase & improve responsiveness • Enhanced health support to care homes is not consistently offered across the country 9 | 9 |
Social Care • Wellbeing of older people and pressures on the NHS linked to how well social care functions • When agreeing the NHS’ funding settlement government committed to ensure that adult social care funding is such that it does not impose any additional pressure on the NHS over the coming five years ‘That is basis on which the demand, activity and funding in the Long Term Plan have been assessed’ 10 | 10 |
A tactical approach to managing complex needs nationally 2017-18: introduction of the GMS frailty requirements • Routine identification of severe (and moderate) frailty • Annual medication review and falls risk identification • Sharing frailty information via the Summary Care Record 2019: NHS Long Term Plan • Ageing well community MDTs for 1.2m people with moderate frailty • Urgent community response • Crisis response delivered in 2 hours • Reablement delivered in 2 days • Guaranteed offer of enhanced health in care homes
Ageing Well-new model for people with complex needs • Funding for delivering the three models agreed through the LTP process – includes central funding agreed specifically to support delivery of the 2 hour / 2 day standards by 2023/24. • Joint workforce planning would be a common golden thread running through all the 3 workstreams. Urgent Community Response • Deliver clearly defined crisis response services within two hours of referral across the country – within five years to avoid unnecessary hospital admission and support same day emergency care • Deliver clearly defined reablement care within two days of referral to all those judged to need it across the country – within five years to reduce unnecessary hospital stays Enhanced Health in Care Homes (EHCH) • Upgrade NHS support to all care home residents who would benefit by 2023/24, with the EHCH model rolled out across the country across the next decade as staffing and funding grows Community Teams • From 2020/21 have primary care networks assessing local populations at risk and working with local community services to support people where it is needed most through targeted support • Support the expansion of the existing community dataset • Support the commitment to greater recognition and support for carers
Key LTP Commitments - UCR: 2 new service standards 1.8 a) – All parts of the country will implement and improve the responsiveness of community health crisis response services to deliver the services within two hours of referral in line with NICE guidelines, where clinically judged to be appropriate 1.8 b) – All parts of the country should be delivering reablement care within two days of referral to those patients who are judged to need it 1.8 c) – More NHS community and intermediate health care packages will be delivered to support timely crisis care, with the ambition of freeing up over one million hospital bed days by 2023/24 13 | 13 |
Key LTP Commitments - Community Teams 1.9. The £4.5 billion of new investment will fund expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices . Most CCGs have local contracts for enhanced services and these will normally be added to the network contract. Expanded neighbourhood teams will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and AHPs, with social workers and the voluntary sector. 1.17 Using a proactive population health approach focused on moderate frailty will enable earlier detection and intervention to treat undiagnosed disorders. Based on their individual needs and choices, people identified as having the greatest risks and needs will be offered targeted support for both their physical and mental health needs, which will include dementia and frailty. 14 | 14 |
Key LTP Commitments - EHCH: the care home guarantee 1.15 – We will upgrade NHS support to all care home residents who would benefit by 2023/24, with the EHCH model rolled out across the whole country over the coming decade . 15 | 15 |
Enhanced Health in Care Homes model Enhanced Health in Care Homes • A programme that will roll out the successful III Care Home Vanguards ‘ Enhanced Health in Care Homes (EHCH)’ model nationally to help address variability in access to health care and ensure that all care homes residents Case study receive holistic/integrated care Analysis of the Wakefield Enhanced Health in • The programme will involve the delivery of Care Homes programme has shown a 27% enhanced primary care/specialist support in reduction in ambulance calls from care homes care homes, regular multi-disciplinary team for falls, and a 28% reduction in hospital bed resident reviews, aligned with rehabilitation days. services where these are provided, and support timely access to out of hours support and end of life care • Intended key outcome : improving the provision of care across all care homes. Domain 7 of EHCH framework is around Data and Technology. A key work programme associated with it is the NHSmail for social providers to improve communication between health and social care. 16 |
Integrated Care • Digital Solutions focused om the individual; enabling excellent medical supervision, with contributions from a truly multidisciplinary team. • Irrespective of where the person is located, whether in a hospital, care, home , or as most people are, in their own home. • However, despite pockets of good practice, currently information sharing with social care providers to support the person is in the main, still posted or faxed. • Digital information sharing between health and social care systems appears to be largely absent. 17 17 | |
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