In March 2015, NHS England and its national partners announced the first of 29 new care model vanguards.
There are six enhanced health in care home vanguards which will offer older people better, joined up health, care and rehabilitation services.
These vanguards were selected following a rigorous process, involving workshops and the engagement of key partners and patient representative groups.
Enhanced health in care homes – offering older people better, joined up health, care and rehabilitation services.
24. Connecting Care – Wakefield District
25. Gateshead Care Home Project
26. East and North Hertfordshire Clinical Commissioning Group
27. Nottingham City Clinical Commissioning Group
28. Sutton Homes of Care
29. Airedale & Partners
Patient population: 360,000
The partners participating in the proposed model to enhance integration with care homes and social care are Age UK, Wakefield District Housing, general practitioners, Nova (support agency for voluntary and community groups), Wakefield Council, Yorkshire Ambulance Services, South West Yorkshire Partnership NHS FT and The Mid Yorkshire Hospital NHS Trust. Practices within NHS Wakefield CCG have a registered population of 360,000 people.
The model of care is designed to break the mould for older people in care homes, tackling social isolation and shifting from fragmented to connected care. They will develop a comprehensive approach to proactive assessment and care planning based around the wider determinants of health ‘somewhere to live; somewhere to love; something to do’ to optimise residents’ health and life experience.
This would mean, for example, that an elderly patient in extra care housing could be supported to resume their hobby of walking following a hip replacement, helping to improve both physical health and quality of life.
The partners proposing to work together to enhance health within care homes are Gateshead CCG and Gateshead Local Authority. Gateshead has a population of around 206,000.
A new organisation will be created called the Provider Alliance Network (PAN), which is to deliver the Gateshead integrated community bed and home-based care service. PAN will provide holistic care and seamless support across the traditional health and social care boundaries. PAN will also oversee and connect healthcare for a population who are cared for and supported in long and short term stay community beds as well as helping those individuals in their family home undertaking reablement, rehabilitation and recovery services at home.
The principal changes that are planned to the delivery of care include the development of co-commissioning of all community-bed and home based care; capitation-based payment system based on need; and outcome-based contract in place. By 2016 PAN and its commissioners expect to see: co-commissioning of all services except those in the private sector; completion of the analysis around health-related and public sector social care costs; and completion of the milestone metrics and outcomes.
The vanguard is a joint approach by NHS Newcastle Gateshead CCG and Gateshead Council. Gateshead we has a long successful history of developing integrated support for patients in community beds (i.e. care homes) to improve patients’ experience and reduce unnecessary admissions to hospital through collaborative working. Although the component parts are in place there is still work to do to bring these parts together into a whole system sustainable model.
The Gateshead model will build on a well-established proactive ‘ward round’ based service that sees GP practices and community nursing teams aligned to care homes across the borough. Personalised care delivery and multi-disciplinary working is starting to see successful reductions in avoidable hospital admissions, together with an improvement in the quality of care delivered.
The next steps through vanguard acceleration will focus on cementing these principles for a wider cohort of patients and families who currently access home services (e.g. intermediate care). Above and beyond the care provision, the vanguard will support the development of a sustainable model through establishing an environment of co-commissioning and co-provision of services with an outcome-based payment system that promotes value for the health and social care economy.
The vanguard is made up of Hertfordshire County Council, East and North Hertfordshire Clinical Commissioning Group and Hertfordshire Care Providers Association.
All of the care provider organisations in the east and north of Hertfordshire are committed to supporting and continuing to improve the care for its most vulnerable elderly residents.
The Vanguard will focus on enhancing the skills and confidence of care home staff through a package of education and training.
The programme will create dedicated multi-disciplinary teams for care homes which will include GPs, community psychiatric nurses, district nurses and geriatricians. They will work with homes to support residents proactively as well as if a resident’s condition deteriorates. They will develop a rapid response service so that care homes have access to services in two localities with a combination of community nurses, matrons, therapists and home carers who can be deployed within 90 minutes if required.
This means care home patients will be supported in the home by staff that are accredited because they have undertaken a package of education and training. In addition, patients will know that should their condition deteriorate, a team of experts is ready to respond to their needs before making an assessment as to whether they need to go to hospital.
Patient population: 342,000
Nottingham City CCG covers a registered GP population of 342,000 and 60 GP practices. The CCG’s application to work collaboratively to provide models of enhanced care in care homes was submitted in partnership with Nottingham CityCare Partnership, Nottingham University Hospitals NHS Trust, Nottinghamshire Healthcare NHS Trust, Nottingham City Council, Age UK Nottingham and Nottinghamshire and local primary care providers.
The proposed new model will provide a structured and pro active approach to care, complemented by a number of local innovations including: mobile working for primary care; access to SystmOne for care homes; remote video consultation between care home residents and GPs; remote access to resident health data through telehealth; and increased use of telecare.
The new model will ensure that all potentially long hospital stays are proactively managed and will build on work already initiated with acute trusts, care homes and community services to develop a ‘pull’ approach to acute discharges, ensuring that social services are involved at the earliest opportunity. Effective mechanisms to capture the experience of patients discharged into a care home setting will ensure a responsive ‘learning lessons’ feedback loop, so services can be continually adapted and improved.
Patient population: 203,000
Sutton Homes of Care covers a registered GP population of 180,000 and 27 GP practices. The vanguard application has been made in partnership with London Borough of Sutton, Age UK Sutton, the Alzheimer’s Society, Epsom & St. Helier Hospitals NHS Trust, South West London & St. George’s Mental Health Trust and Sutton and Merton Community Services (the community division of the Royal Marsden).
The Vanguard site will develop a care home provider network to support training across local care homes, and a new model of health and social care locally, which will include telehealth and expanded in-reach services, providing the right care at the right time where patients need it.
This means a patient who has three in-patient hospital stays in a month will now get the care they need from hospital specialists at home, enabling them to stay close to their family and friends.
Patient population: 506,000
The Airedale Partner’s Vanguard objective is to enhance the quality of life and end of life experience of thousands of nursing and care home residents living in Bradford, Airedale, Wharfedale, Craven and East Lancashire.
The Vanguard application was made in partnership with a number of organisations including CCGs and their member practices, NHS providers, care home providers, social services and the third sector. Technology partners and academic partners including the University of Bradford have also supported the bid.
The partners have a track record of innovative enhanced care delivery for this group of vulnerable, frail elderly people, many with multiple long term conditions including dementia and often approaching end of life. By using enabling technologies, such as telemedicine, the Gold Line and Intermediate Care Hub, nursing and care home residents and their carers are already benefitting from being able to access expert advice and support remotely 24/7.
Through the Vanguard programme, partners intend to go further and develop a more proactive health and social care enabling model focusing on optimising residents’ individual capabilities and building new clinical models of care. This model will be enabled through technology and an extended use of telemedicine, providing a single point of access to all aspects of specialist health and care advice.
This will mean, for example, that a patient with Parkinson’s disease living in a residential home will be able to access clinical advice and support through secure video conferencing at any time of the day or night. So in the event of a fall, an experienced nurse in the telehealth hub will be able to assess the patient using the video link and after consultation with an A&E consultant will be able to arrange for them to be cared for in their familiar surroundings, rather than transferring them to A&E.
In addition, the enhanced care model provides links to social care to complete a falls prevention assessment of the layout of the patient’s room, and a multidisciplinary team including carers, nurses, therapists, social care and the voluntary sector works in partnership to deliver care and support, promoting independence and improving quality of life.