Jacqui BunceAssociate Director

Chris BadgerAD Integration CCG & Herts CC

The Change Challenge

‘Develop integrated physical, mental health and social care pathways to prevent inappropriate

hospital admissions’

GPs, CCG Associate Directors, Social Care Senior Managers

Impact & Benefits• Improved relationships between Health

& Social Care• Protected time for learning &

Development• Skills and competencies to take forward

large scale change• More confidence in using tools &

techniques• More confidence in questioning

challenging data and use of metrics• Tangible resultant outcomes for

patients:– ESD, Homefirst, Better Care Fund

Highs & LowsEnjoyable

Relationships developed

Positive relationship with key NHSIQ facilitators

Tools and techniques, e.g. SPC

Time commitment

Staff changes

Role of elected Members?

How to engage providers?

Significant Tools & Techniques

To ensure 60% of people

who have expressed preferred place of death

achieve it by 2019

Find out where they want to die Find out where patients and carers know their preferred place of care for death

Ensure resources are available delivered to support different choices of PPD

Get ACP/PPD in place

Share ACP/PPD

Culture where people expect to discuss death to PPD / culture of death being demedicalised

Identify resources needed and commissioning contracts

AIM PRIMARY DRIVERS

SECONDARY DRIVERS

IN

TE

RV

EN

TI

ON

S

Social services contact with older people – death wish 50% of SC manager interactions include discussion ACP by October 14

ACP talk and agree plans with those with LTCs

Advanced care planning: GPs / hospital / community / nursing homes

Develop support for families in helping them agree ACP / PPD

GP contact with older people – death wishSingle assessment – advanced care plans. Consent - DNAR

Develop a consistent way of recording ACPPlace of residence i.e. patient’s home – clear about ACPs

Staff education on how to do DNAR

Apps or IT programs available to make online choices

Train staff in discussion / recording of ACP (HCP / SCP / residential nursing home staff)Funeral plan – incorporate ACP / PPD / death wishes into pre-payment plans

Funeral directors learn how they talk - ACP/PPD/death wishes – training?

Collate responses

Carer support and training for carers of patients who are palliative

Peer support development

Amber project

Public education: value of ACP / PPD

AIHVS

Create entry on patient record / social care file

Ensure each provider ensures everyone in organisation knows the client’s ACP 100% of patients with ACP have them avail in the notes

Agree a process for sharing ACP/PPD with providers % admissions from NH for EoLC

Good death for patient and family – who gets to decide? Post-death

What support do families get after the death?

Engage with carers

Living will

Perceptions about death in society / from films / as failure / dramatic & unpleasant

Power of attorney

Develop community services to support EoL care at home Care home 1° care

project

Holistic assessment unitA&E navigator

NH contract for 1° care to encourage high quality ACP/PPD - KPIs

Acute medical consultant triage

Create capacity to fulfil expectation

Standalone unit – hospice and hospital

Nursing home staff to avoid admissions for EoL patients

Staff in care homes are trained and not risk averse

How do we enable/commission hospital to provide approp. EoL care?

Ambulance Trust – avoid admissions

Voluntary sector roles

Keep a shared register move to share ACP / PPD

Develop hospice services for those choosing them on PPD

Dedicated block capacity for fast track care

Comms. strategy

Ensure all staff in partner organisations have awareness of how to do a DNAR

50% SC records with ACP for O75s asked if they knew about ACP and want to start the processAcute care

colleagues to engage with supporting good deathsNo. of funeral directors participating in the project / who has bought a funeral plan in the last 5 yrs

90% of NH pts with PPD at home achieve wish 12/12

No. of admissions by Nursing Homes by condition per quarter

Register of shared ACP / PPD

Balancing measure: 1. reduce bed

occupancy for EoL patients

2. Increase home care costs

Statistical Process Control Charts

Used , and understood,

across Health and Social Care

What challenges have you faced and how did you overcome them?

What contribution has the NHS IQ programme made?

We’re on a journey………

Health and Social Care …… Speed Dating

What was most useful about the programme?

Relationships across health and social care

Joint understanding of health and social care commissioning

Underpins ambitious Better Care Fund of c.£120m

If you knew then, what you know now, what would you do

differently?• Think differently about elected

member engagement• Spend time earlier on shared health

and social care issues• Understand need to co-design with

NHSIQ and be flexible

What are your personal insights, reflections and learning?

• Relationships drive integrated care• Successful transformation of care built

on effective relationships across health and social care system

• The importance of quality, facilitated, time-out to plan and deliver change

Taking things forward