PRIMARY CARE CONTRACT NURSING & RESIDENTIAL CARE HOMES Right place, Right time, by the Right...

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Transcript of PRIMARY CARE CONTRACT NURSING & RESIDENTIAL CARE HOMES Right place, Right time, by the Right...

  • PRIMARY CARE CONTRACT NURSING & RESIDENTIAL CARE HOMES

    Right place, Right time, by the Right person

    Shivaun Aveston, Transformation Lead

  • NHS OUTCOMES FRAMEWORKRight place, Right time, Right person

    Domain 1Preventing people from dying prematurelyDomain 2Enhancing quality of life for people with long-term conditionsDomain 3Helping people to recover from episodes of ill-health or following injuryDomain 4Ensuring people have a positive experience of careDomain 5Treating and caring for people in safe environment and protecting them from avoidable harm

  • The CCGs 5 year Clinical Strategy& Joint Health & Wellbeing Board

    To improve care for frail elderly individuals

    To allow patients to die with dignity and compassion and in their place of choosing

    Older people in Suffolk have a good quality of life.

  • Investigation into provision of GP services to care homes has shown that most care homes allow residents to choose a GP. This can result in different GPs visiting a single care home to see different patients This is an inefficient use of GP time and resources, but can also cause problems with communications as nursing homes have to deal simultaneously with several different systems for visits

    Chronic disease management and prescription requests many homes would prefer their residents to be registered with just one GP surgery and have a weekly clinic to deal with minor problems and chronic illness.RCGP Report Preparing for the Future (2012) states:

  • HEADLINE COSTS 2011/2012Emergency Admissions 6m

    A&E 2m

    Ambulance Call outs 2m

    Care homes represent 25% Ambulance call outs

    25% of falls originate from Care homes

  • TOP 10 REASONS FOR ADMISSION TO HOSPITALHip Fractures

    UTIs

    Pneumonia

    Disorientation

    Femur FracturesHeart failure

    Respiratory infection

    Falls

    Cerebral infarction

    Senility

  • KEY ISSUES FOR CARE HOMESHigh level of different GPs

    Key time for admission are within OOH

    Time waiting for clinical support

    Advance Care plans overridden

    Untrained staff

    Staff competencies

    Lack of specialist provision Physio,OT

  • THE STORY SO FAR

    Small Pilot in East Suffolk 36 Care HomesNurse practitioner/GP/Nurse offering additional supportInequalities in the provision of care across the patchCCG want to spread good care and equity to this marginalised group and provide a better patient experience for them

    OUTCOMES

    Improved clinical care Reduced admissions to hospitalReduced call outs to OOHReduced ambulance call outs

  • KEY COMPONENTS OF THE CONTRACTOctober March initially29 practices aligned to Care homesWeekly ward rounds- proactive management ProtocolScreening- Dementia & FallsCare Planning, Advance Care Planning (Yellow Folders)Medication ReviewFollow up after admission/OOH Multi- Disciplinary approachSupport Care homes through training

  • NOT IN SCOPEEMI Units

    Sheltered Housing

    Private Retirement Schemes

    Learning Disability

  • IMPACT EVALUATIONQuestionnaire- Pre & Post

    Activity Report (GPs)

    Clinical Audit

    Care Homes Dashboard

  • CONTACT DETAILSShivaun AvestonTransformation Lead, Redesign TeamRushbrook House Ipswich

    [email protected] 770131Mobile: 07944212642

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