RCCG/GB/13/125 SIGNS & the Frail Older People programme Update to Rushcliffe CCG Governing Body September 2013 Jeremy Griffiths – Chair of SIGNS, Clinical lead
Activity and financial implications (Nottinghamshire)
SIGNS- Frail elderly programme (Strategy & Implementation Group for Notts South) ; a collaboration of commissioners, providers and 3rd sector organisations Commissioners Nottingham City CCG Rushcliffe CCG Nottingham NE CCG Nottingham West CCG Providers Nottingham University Hospitals Nottinghamshire Healthcare Nottingham CityCare Partnership County Health Partnerships Councils & 3 rd Sector Nottinghamshire County Council Nottingham City Council Carers Federation
SIGNS - Strategic objectives • Use time based standards to measure how well the system is performing for the citizen and where priorities need to change • Commit to Comprehensive (Geriatric) Assessment for frail older people (CGA) as the way we all assess frail older people. • CGA 5 domains (physical health, mental health, social and economic status, functional status, environment) a care plan that is communicated to all those who will provide care a case manager to ensure that this all happens. • Enable community services to provide services for citizens in a timely way. Services are proactive, flexible and care that is always appropriate to need. • Integrated with other providers • Reduce numbers moving to care : Citizens moving to residential care receive CGA:plan is enacted before any move. • Treat the avoidable admission or delay in transfer of care of a citizen as an untoward event • Implement a process to truly understand and aim to limit stays of more than 50 days in our hospital and community beds (and a rolling reduction thereafter) • Use differences between the needs identified from Comprehensive (Geriatric) Assessment and current provision to invest in appropriate services.
Strategic priorities for change • Choose to Admit Integration • Transfer to Assess Intermediate care • Support to Thrive • SCOPES (Systematic care for older people in elective surgery) All underpinned by: • Comprehensive geriatric assessment (CGA) • Time based pathway standards
Choose to Admit Comprehensive Assessment at the front door of the hospital • The hospital provides CGA for frail older people as close to the front door as possible (a geographic area(s) rather than a peripatetic service). • A case manager ensures that the Plan from the CGA is communicated. • Where admission is not necessary, staff from hospital, community, primary care, social care, mental health, third and private sectors work together at the front door to provide evidence based alternatives to admission
Transfer to Assess Case Managers ensure timely transfer of care from hospital • The intensity of the care provided will be appropriate for every citizen in a hospital or community bed. • The Case Manager, hospital, community, primary care, social care, mental health, third and private sectors work together to provide rapid and evidence-based alternatives to on-going admission • The citizen transfers from hospital within timescales agreed in our Standards of Care.
Support to Thrive Case Managers ensure timely provision of community based services • Services are seamless from the citizen’s perspective. • Single points of access to health and social care are used by default. • All intermediate care and reablement (recovery and rehabilitation) services are aligned around current citizen’s needs. • Pathways are sufficiently flexible to eliminate the use of the hospital as the carer of last resort.
6 Strategic Priorities aligned to ‘levels of care’ SCOPES Support to Thrive Support to Thrive (planned care only) Choose to Transfer to Assess Admit Comprehensive Geriatric Assessment (CGA) Pathway Standards - time based Enabling sub groups - Outcomes & Commissioning, Communications & Consultation, Workforce Planning Enabling approach - SHARING of information, risks, challenges, successes etc. will be key
Choose to Admit and Transfer to Assess projects Patient Information exchange including Alerts 1.Care co-ordination team 3.Community 2.Community 2.Community 3.Community (underpinned by NUH’s capacity Access Access capacity – flow, streaming, discharge project) 4. CGA / case 4. CGA / case 4. CGA / case management management management
Next 3 months (as at 5 th Sept) Choose to Admit/Transfer to Assess - Planned deliverables By 1 st Dec 2013 By 1 st Oct 2013 By March 2014 Establish single integrated Care Co- Current resources working as Care Co- ordination Team to support Choose to one team to support ED, ass ordination tbc Admit and Transfer to Assess, beds and 8 HCOP wards (14 th reconfiguring existing resources, to Team October) case manage all ‘supported transfers’ Community hubs manage all health CCG-based community hubs Community hubs able to and social care local service capacity established with access to a commission reablement Community and organise packages of care to clinician with streamlined services Hubs support transfer from hospital within interface to Care Co-Ordination 24 hours Team Community capacity (bed and home 21 beds that are staffed to based) increased to meet the needs of meet the needs of the most patients on HCOP and medical wards. Community complex patients as part of an capacity integrated community service New commissioner model for community places agreed for County and City Standardised transfer of care Transfer of care template Agree and implement a method of CGA and template used to share operating electronically on recording and sharing CGA across information information on needs SystmOne primary care, social care, NUH and between NUH and sharing community services community hub (fax)
Next 3 months – other priorities SIGNS approved proposal re: Oncology will go to readmissions SCOPES panel and if successful, recruitments / implementation will start (planned care only) Strategy will be developed - for CGA approach to be implemented CGA across Greater Nottingham Support to Initial scoping work and development of strategic direction Thrive Comms plan developed and approved by SIGNS on Sep10th. Communication Implementation of first 3 months of activity
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