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Preserving health and independence in later life

People living in care homes are up to three times more likely to end up in hospital than other over 75s. But system leaders implementing a newly developed Enhanced Health Framework are seeing profound improvements in quality of care and reductions in avoidable activity:

It’s just over a year since NHS England’s New Care Models programme published a framework for enhancing the health of older people in care homes.

It was drawn together from the experience of six vanguards – local health and care partnerships – that were chosen to deliver change on the ground for tens of thousands of care homes residents.

We developed the framework to help other parts of the country redesign care, and we were inspired to learn how two particular Clinical Commissioning Groups and their partners – Hardwick and North Tyneside – are adopting and adapting the model.

With the pressures of winter, it is incredibly inspiring to hear how the lives of older people, some with profound health and social care needs, are being improved.

In just 12 weeks, Hardwick has made astonishing progress across many of the care elements of the care homes model, with little or no additional funding. While North Tyneside CCG has adopted the whole framework, despite previously being a severely challenged health economy.

Ruth Cooper, a GP in NHS Hardwick CCG sets the context:  64 care homes generating close to 1,500 emergency hospitals admissions a year, costing more than £3million, with about 7,800 ambulance callouts.

They launched a change programme, bringing together a core team of expert practitioners and managers to identify a set of problems to solve using the care homes framework to structure their approach.

For instance, they discovered a high level of ambulance callouts resulted from older people falling. A medication review by a pharmacist found that nearly all fallers were taking more than four medicines, some which unambiguously increase the likelihood of a fall. Where appropriate, they reduced the medication residents were on, decreasing the risks of falling and hospitalisation, and cutting costs. Policies were also changed to avoid inappropriate prescribing and a falls ‘MOT’ was introduced to flag potential risks sooner for other residents.

A physiotherapist and occupational therapist reviewed equipment in homes, finding that at least 60% of the equipment in three care homes needed changing. One resident with dementia and severe disability was provided a specially adapted chair, improving their breathing and nutrition, the use of their arms and their ability to engage with loved ones.

Another review discovered confusion about the way specialist community beds could be used. By simplifying referrals and ensuring round-the-clock professional support the occupancy of these beds has improved, making it easier for patients to readjust after hospital treatment, and reducing the risk of readmission back into hospital.

In North Tyneside, wide health inequalities mean that the life expectancy of a resident varies by nine years depending on where they live in the area.

Gary Charlton, the Commissioning Development Manager at NHS North Tyneside CCG, says they have aligned GP practices to each nursing and residential home to enhance primary care support.

Pharmacists are reviewing medications routinely and there is now specialist nutritional support for care home residents. They are also piloting an app to monitor residents’ hydration levels.

Specialist teams are working more closely together to manage conditions, such as continence. Their rehabilitation support has been redesigned – a specialist unit has been introduced and a peripatetic team helps patients to leave hospital as soon as possible and receive rehab back in their home.

They’ve appointed a specialist palliative nurse to improve end of life care for care home residents, and all homes have a rolling programme of training in end of life care.

So this gives a flavour of what can be achieved.  Both Hardwick and North Tyneside have avoided spending lengthy periods of time building business cases for change. They are using insights from their residents and staff, and the achievements of new care model vanguards, to lay the building blocks for change – and they’re getting on with it.

Success is very dependent on building good relationships, sharing goals and having a stake in the ‘game’ where health and care teams can take ownership, solve problems faster, and make best use of their expertise. And, as we are seeing, other parts of the care system are learning fast from the vanguard programme that is making such a difference to older people’s lives.

Liam Paul

Liam Paul is a Policy Manager in the System Transformation Group, now helping Accountable Care Systems (ACS) to design, test and implement system control totals and new payment mechanisms.

Prior to this he co-authored the Enhanced Health in Care Homes framework and worked with vanguards, STPs and accountable care systems to help them implement it.

Before joining the NHS, Liam supported councils to implement the Care Act 2014 and worked on health and social care improvement for the Local Government Association.

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