Older People and Integrated Care Update PEG – 24 th January 2019 Annette Bunka – Head of Older People and Integrated Care, Merton Simon Galea – Project Manager, Older People and Integrated Care, Merton
Overall Objectives • Keeping people well at home • Delivering care at home or closer to home where possible • Reducing the demands for emergency services, including London Ambulance Service (LAS) calls and the need for transport to hospital. • Avoiding Emergency Department attendances and avoiding/ shortening emergency admissions and optimising discharge processes • Improving integration across services and the user/carer experience 2
Priorities Integrated locality teams, including support for those identified with frailty and end of life care Supporting discharges from hospital Enhance and broaden the scope of intermediate care provision Enhanced support to care homes Supporting older people with multiple long term conditions 3
Integrated Locality Teams & Frailty • Multi – disciplinary working across health and social care • Each GP practice in Merton has committed to working in 1 of 4 groupings (clusters), with a scheme incentivising GP practices to provide additional support for complex patients. • Community services have aligned their nursing teams to the 4 clusters. • Each practice has a Health Liaison Social Worker from London Borough of Merton. • 5 Co-ordinators have been recruited to support the most complex patients, those with severe frailty and those who are in the last year of life. • SW London and St George’s Mental Health Trust have identified a liaison point of contact for all practices. • St Raphael’s Hospice attend practice multi -disciplinary team meetings. • Improvements in care planning, including 733 patient held admission prevention plans and 320 Coordinate My Care records. 4
Frailty • Proactive identification and review of those who are living with frailty: • Locally adapted Healthy Ageing Guide distributed to GP practices, community services, libraries, social care and voluntary sector. • Where required, referral to appropriate services e.g. falls prevention classes, case management/ care navigators. • Healthy Ageing Guide being updated- comments welcome 5
Supporting Discharges • Integrated Intermediate Care Single Point of Access started in December 2018 – This is a single point for triage and case allocation for those who may require interim support/ rehabilitation. • Initially this has been set up for referrals from acute trusts to support smoother discharges. • This will be expanded to support admission prevention in 2019/20 • Daily review of patients at St George’s and a weekly escalation meeting has reduced delayed transfers and supported earlier discussions about complex discharges and improvements in information to support patient transfers. 6
Enhance and broaden the scope of intermediate care provision • A new bedded provision, which will be run by community services is due to open late February 2019, which over time will enable increased scope for more prevention of admission. • Older people’s liaison service at St George’s now also works within the Emergency Department and health and social care are working more closely to help people out of hospital sooner. • Working on a case for GP Input into the Rapid Response service (MERIT) which aims to provide a rapid response to support people in their own homes and more GP input into the community beds. 7
Enhanced Support to Care Homes • Red bag pathway launched in 21 nursing/ residential homes on 29 th January 2018. • Red bags contain important information about the resident’s health. • Care homes have reported usage of the red bag on 70 occasions from Feb-Nov 18. 8
Enhanced Support to Care Homes • Merton Joint Intelligence Group continues to meet monthly to improve quality and Merton Care Home Forums taking place regularly. • A programme of care home training in relation to identified priority areas is being delivered (complementing support/ training that is already provided). • Funding agreed from Health Education England to support training including falls prevention • Through the range of initiatives there has been a reduction in emergency transport from care homes, instead using support from community services. • A proposal is being drawn up to provide more input and support to care homes across Merton and Wandsworth. 9
Older People with Multiple Long Term Conditions • Giving patients the option of a referral for an holistic geriatric assessment (HARI) instead of attending multiple outpatient appointments. • Making greater use of the HARI service at Nelson • Look holistically at the person, their level of frailty and the risks and interactions of using multiple drugs to treat one or more conditions. • Undertake patient engagement to develop appropriate communications to encourage patients to ask for the change – views welcome 10
Thanks for listening. Any questions? 11
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