Care for Older People Tuesday 14 May 2019 2pm to 4pm Developing - PowerPoint PPT Presentation

Members’ Event: Integrated Care for Older People Tuesday 14 May 2019 2pm to 4pm

Developing Pathways of Care for Frail Elderly Therapies and Older Persons Program Medway NHS FT Dr Sanjay Suman April Thompson Alison Streatfield Clinical Co-Director (Medical) Head of Therapies Clinical Co-Director (Nursing)

Agenda • Introduction- why are we here? • Where have we come from • Where are we now • Where are we going • Q&A

Introduction – why are we here? • What is the programme? • Who are we? • What do we want from you….?

Frailty is best viewed as a long term condition Trajectory of Decline Isolated Dependence Disability functional decline Incapacitation Progressive functional decline

Clinical Frailty Scale: Tool to identify frailty

Comprehensive Geriatric Assessment (CGA) Gold Standard for frailty management MDT Role INDIVIDUAL CARE & SUPPORT PLAN • How frail is the individual (Trajectory) • Managing acute illnesses • Optimising underlying co-morbidities Psychological • Optimising Polypharmacy • Optimising physical function • End of Life decision making Social • Family meeting / managing expectations • Ceiling of care Functional • Criteria for Discharge • Expected Date for Discharge Medical • Identifying and meeting care needs

Trust strategy Our values put our patients first and inspire us to be the B.E.S.T BOLD – We are inspiring and ambitious EVERY PERSON COUNTS – We are respectful and supportive SHARING AND OPEN – We are open and speak up TOGETHER – We are inclusive and responsible HIGH QUALITY CARE Financial Integrated Innovation Our People Stability Healthcare Supporting Strategies System Financial Workforce Clinical Strategy Quality Strategy Recovery Plan Strategy Key enabling initiatives Continuous Transformation Culture Integrated Digital Estates Strategy Improvement Programme Programme Partnership Transformation

Where have we come from? Developments since September 2018 MFT Frailty Village Frailty Flow “Poet’s Wing” Sapphire Acute November / January 2019 ED / Medical Frailty Unit (SAFU) December 2018 Assessment Unit October 2018 September 2018 • Frailty “stocktake” workshop held (22/01) to: • Establishment of SAFU  Finalise MFT Frailty • Huddles / Board Rounds Dedicated Multidisciplinary Village 3- 5 year vision – • Team (Nursing, Medical,  Consolidation of Board MDT Embedded: Front Door “Ideal State” Therapies, Pharmacy, Therapist, Frailty Specialist Rounds and daily Huddles  Develop Cycle 1 BBB Discharge Team) Nurses, Pharmacist) with MDT engagement Improvement • Consultant-Led Unit •  Development of Frailty Identifying Frailty in ED (Clinical programme workstreams Frailty Scale applied) • Specialist Nurse roles to Focus areas: (see slides) which support flow directly to • includes the Frailty “Hot Consultant led pathway: 7  Rapid turnaround (<72 SAFU and Frailty bed base Clinic” mobilisation for days, 12 hours hours) (FBB) GP rapid access • Comprehensive Geriatric  Improvements to the • Official opening of SAFU  Introduce the BBB assessment commenced in ED physical space befitting of 13/12/18 Improvement • a frailty unit i.e. Frail Patients streamed to methodology into Frailty Enablement Café, Acute Frailty Unit or Frailty Bed to realise vision Dementia-friendly garden Base depending on Expected Date of Discharge

Where we are now? Poet’s Wing : Medway’s Acute Specialist Frailty Village Vision Statement “… .A specialised acute wing receiving emergency admissions directly into the care of the Frailty Service using evidence-based best practice interventions to support exceptional care for frail patients. Poet’s Wing will provide a comprehensive multidisciplinary assessment and inpatient service for frail people requiring acute, hospital-based support. The wing will also house ambulatory care for unplanned and planned patients requiring non-inpatient support, which is directly accessible from primary and emergency care … . ”

October 2018

The Butterfly Garden Poet’s Wing : Medway Hospitals first dementia friendly therapy garden.

Where are we going? • Optimise flow To reduce the average length of stay (LoS) for frail older patients to an average of 10 days across the Frailty Bed Base and 72hrs within Frailty Short Stay (SAFU); • To optimise the number of frail older people returning home on the same day; • To reduce the pressure on other emergency pathways and services who do not specialise in the care of frail older people. • Improve safety & To accelerate the initiation of appropriate clinical interventions for frail patients who do quality require admission; • Reduce avoidable readmissions among the frailty patient cohort; • Reduce the associated incidences of hospital-related harm and deconditioning for admitted frail patients; • To meet the quality standards of the Silver Book to provide CGA for all patients presenting with frailty syndrome within 2 hours (14-hours overnight); • Enhance patient Reduce the number of inpatient ward moves and encroachment into other specialty beds; experience • Provide a more personalised care approach for all Frail patients and their families / carers to ensure the acute stay is minimised and patients safely return home as soon as possible • To reduce the direct and indirect costs associated with increased length of stay to the Improve sustainability acute trust, community and third sector partners and patients themselves; • To enhance the Trust’s reputation and become known for providing exceptional care for frail patients – and thereby be in a position to recruit and retain specialist staff.

We want to lead in Higher Quality Care Awaiting Decision Ready to Transfer Commun Medically Home unwell present Assess Admit Place Treat Transfer Inpatient to Admit Fit leave of Care ity of Care We are listening to you and investing in a programme to improve our capacity to provide safe, quality, value for money care.

Why? • Because we believe that best care will be achieved by the right person, in the right place, at the right time. • ‘ T here’s no place like home ’ and that safe, timely discharge is our goal. • We believe that our people deserve the opportunities and support to arrive at work knowing that they are empowered to contribute to the delivery of high quality care and leave knowing they have delivered. • We believe that working with partners we can improve the outcomes and efficiencies for the people we serve across our local health and social care system .

Thank You SAVE THE DATE! Our next members’ event ‘A taste of Medway ’ will be on 9 July 2019.