West Hertfordshire Health and Social Care Projects

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1 West Hertfordshire 00

2 Introduction Health and social care organisations in west Hertfordshire are designing new ways to help people get the health and social care they need. This leaflet provides some examples of the innovative projects that are already supporting people. Many of the services which are highlighted reflect the growing need to join and integrate care which often involves multiple organisations working together to meet the needs of an individual patient. Access to appointments, faster discharge from hospital and support at home to help maintain older people s independence are just some of the other initiatives under way in west Hertfordshire. Complex Care Premium What is the Complex Care Premium? People are living longer and, as we get older, we tend to make more use of health and social care services. The ageing population has led to a rising number of care home residents living with more complex conditions. These residents may need more support than other residents, and are more at risk of falling, being admitted to hospital or experiencing another type of incident. The Complex Care Premium pilot aims to support care homes in providing high-quality care for people with complex conditions. This support is provided in two stages: It delivers in-depth training for care home staff on caring for complex conditions including dementia, nutrition, falls, wound management and resident engagement. It introduces a weekly enhanced rate or Premium for care homes to use to support residents with complex needs. The Premium will improve care for older and vulnerable people in care homes by making sure they receive the right care in the most appropriate place. This will: Help stabilise residents complex conditions. Reduce the likelihood of a resident being admitted to hospital or using other services unnecessarily including ambulances, community nurses and GPs. Speed up discharge times from hospital to care homes. Ensure care home staff feel confident in the care they provide - each home will have five complex. care champions who will lead improvements in care quality. Staff training and payment of the Complex Care Premium will begin later this year for about 20 residential and nursing homes. Following evaluation after six months, it is expected the scheme will be made available to a larger number of care homes. 1 2

3 Family Nurse Partnership What is the Family Nurse Partnership? The Family Nurse Partnership programme provides help and support to young first-time parents living in west Hertfordshire. It provides young women and their partners with special access to health services during pregnancy and up until their baby is two years old. Family nurses support mothers aged 19 or under by helping them to set goals and plan for their family s future. They work closely with health visitors, midwives and professionals from other services. After signing up to the Family Nurse Partnership, specially trained nurses visit young women and their partners at home and advise on topics such as staying healthy and well during pregnancy, supporting a child s health and development, and managing finances. Young women need to be signed up to the scheme by the 28th week of their pregnancy and families have weekly, fortnightly and monthly home visits by family nurses throughout the programme. The service supports approximately 50 young women in west Hertfordshire every year and 100 in east and north Hertfordshire. I have a family nurse there to ask things and I have constant support, I can drop a text anytime. - Client HomeFirst What is HomeFirst? HomeFirst is an integrated, multidisciplinary, health and social care service that has been running in Hertsmere since January It is a partnership between Hertfordshire County Council, Herts Valleys CCG and Hertfordshire Community NHS Trust and aims to give patients the care and support they need in their own homes to prevent unnecessary hospital admissions. The team is made up of highly experienced doctors, nurses, physiotherapists, occupational therapist, social workers, community matrons, health care assistants and homecare workers who all have years of experience of caring for patients in the community. The service operates from 8am 10pm, seven days a week in the Hertsmere area. HomeFirst accepts referrals from all health and social care professionals including GP, hospitals, ambulance service, social care, and Herts urgent care. The service has two elements: Rapid Response and Virtual Ward. RAPID RESPONSE: This service consists of a rapid intervention, multi-disciplinary team designed to respond to referrals within 60 minutes if required. The team will respond and undertake a full assessment and provide the necessary medical, social care, nursing or therapy support to keep the patient in their home if appropriate. VIRTUAL WARD: This involves putting in place a whole system case management approach, where health and social care professionals work together to provide patients with proactive multidisciplinary, preventive care at home. Patients are identified before they are in a crisis using a risk stratification tool or through referral from the patient s GP. The result More than 1,960 patients have been supported by the service since its launch. The service has had a significant impact on reducing emergency admissions in the Hertsmere locality. Being able to refer to an acute (community) medical and social care team who communicate with each other has been very extraordinarily valuable. - GP 3 4

4 Innovation in health and social care in west Hertfordshire is important so that services continue to meet the needs of residents. This infographic sets out some of the key challenges facing services in the area today. 5 6

5 Host Families What is Host Families? Alongside professional help for people with mental health problems, sometimes people just need to be part of a family and to feel safe within a neutral, regular home for a few weeks in order to restore their wellbeing. The Hertfordshire Partnership NHS Foundation Trust s award-winning Host Families scheme is an innovative and unique service that provides an alternative to hospital admissions for mental health service users. Focusing on recovery, the service offers choice to patients who are experiencing an episode of acute mental ill health, providing an option for person centred, therapeutic and safe recovery outside of hospital. Host Families are recruited and supported to offer a home environment to an unwell person as an alternative to acute inpatient care in hospital. Families are supported by mental health professionals and encourage guests to participate in family routines and ensure that they are fully involved in the daily running of the household. The scheme provides: Choice to service users experiencing acute mental ill health. 24 hour support within a safe, community based environment to acutely unwell service users. Good clinical outcomes. A cost effective alternative to inpatient care. To date 120 service users in Hertfordshire have benefitted from the Host Families programme. There are currently eight active Host Families in Hertfordshire, three of which are in west Hertfordshire. I preferred being with a Host Family. I didn t want to stay in hospital too long. Having my own room, my food that I wanted and activities that I wanted to do. I could have had visitors but it was my choice not to. Watford Care Alliance What is the Watford Care Alliance? The Watford Care Alliance is enabling more than 111,000 patients in Watford and Three Rivers to access a GP at a convenient time. Extended opening times at weekends and evening appointments until 8pm are helping patients get the care they need and reduce unnecessary hospital visits. Twelve practices are currently working together to provide 16,000 more GP appointments per year. All patient records are available at any of the surgeries involved in the alliance, so that people s records can be accessed regardless of where the patient is seen. GPs are working in integrated health and social care teams that include a range of professionals such as social workers, community nurses, physiotherapists and occupational therapists. This integrated approach also extends to palliative care so that patients can get the specialist care they need in their own home. The Watford Care Alliance makes it a lot easier for patients to see a doctor at a convenient time. Patients can see a GP seven days a week. People can book an appointment via their surgery, for instance on a Sunday. People can also call 111 and, if required, a GP appointment will be made. Extra services are now available within surgeries which mean that a hospital visit may not be necessary. 95% of patients rate the care good or excellent. More than 5,000 patients have already had an appointment in extended hours, such as evenings and weekends. Over a quarter of those people are likely to have otherwise gone to emergency services or the out of hours service. I was thrilled to find out that the practice is open on the weekend. I am a sales executive and spend most of my week travelling. Seeing my GP was almost impossible for me. I admit that I would end up ignoring health problems because of this (Public) 7 8

6 Improving care for frail and older people What is it about? As the number of people living longer is expected to rise, local NHS and social care organisations have formed the West Herts Older People s Partnership to look at ways of providing services to meet the changing needs of local residents. The Partnership is working with the Care Quality Commission (CQC) and UCLPartners to identify a model of care and the type of support that will benefit frail and older people. This has involved interviews with patients to provide a better understanding of patient journeys and experiences and priorities for older people. The Partnership includes West Hertfordshire Hospitals NHS Trust, NHS Herts Valleys CCG, Hertfordshire County Council, Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire Community NHS Trust and Healthwatch Hertfordshire. The Partnership is committed to improving the care provided for frail and older people regardless of whether they receive care in their own home, a care or residential home, in hospital or another setting. The Partnership will also help to test new ways of measuring outcomes across health and social care, helping to integrate health and social care services and informing national initiatives for measuring outcomes in England. Results of the Partnership will be evaluated in the future. Community Navigators What are Community Navigators? There are 12,000 different voluntary and community groups in Hertfordshire. GPs and social workers can t possibly know about all of them and that means vulnerable and anxious people may not be able to access them. Community Navigators are just that, they help people find the help they need, and will do the research when they don t already know where it is to be found. The programme is commissioned and jointly funded by NHS Herts Valleys Clinical Commissioning Group and Hertfordshire County Council. There are currently five Community Navigator projects hosted by local charities, one for each District or Borough Council area. The Community Navigators work closely with Herts Help - a telephone service for local people to find out about all the different local organisations that could help them - and compliment their work by taking referrals of people who need the Herts Help service, but are unable or unlikely to access it over the telephone. They help people to establish sustainable relationships with the services that can help them, enabling them to feel more supported in their community, and thus less likely to access health professionals for non-clinical needs. GPs, along with health and social care professionals and voluntary sector organisations can refer people to the scheme. It s not just clinical interventions that make a difference to health and wellbeing, social and environmental factors can play a big role too. This scheme is relatively new but it is already supporting people in these areas by reducing social isolation, and motivating people to attend local groups. This also frees up professionals time to manage people who require clinical/formal care intervention, delivering better outcomes for patients and carers and reducing the costs to the health and social care system in the long run. Individual local groups and charities have a real power to help people. This new partnership will give us all a better understanding of what community groups across the board offer to help people stay independent and well. - Colette Wyatt-Lowe, Herts County Council 9 10

7 Our Partners Hertfordshire Community NHS Trust n East of England Ambulance Service For more information please contact: NHS Herts Valleys Clinical Commissioning Group Hemel One, Boundary Way, Hemel Hempstead, Herts. HP2 7YU T E enquiries.hvccg@nhs.net