ESSENTIAL GUIDE The interface between care homes and hospitals: dementia

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1 ESSENTIAL GUIDE The interface between care homes and hospitals: dementia This guide has been supported by This guide has been supported by Dementia Cover.indd 1 25/03/ :32

2 ESSENTIAL GUIDE The interface between care homes and hospitals: dementia This guide has been written by Deborah Sturdy, independent nurse consultant, older people; and Professor Martin Green, chief executive, Care England Contents 3 Introduction 3 Cracks in the Pathway 4 The NHS Five Year Forward View 5 Peninsula Community Health 5 St Christopher s Hospice 7 Cumbria Partnership Trust 8 Enfield Community Services 9 Southern Health and Social Care Trust 10 Conclusion 10 References 11 Resources This guide has been supported by Group educational projects manager Laura Downes RN Editor Lisa Berry Art director Ken McLoone Senior production editor Julie Hickey RCNi The Heights, Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AW For further information contact: Care England Copyright 2015 RCN Publishing Company Limited. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the publishers Cover image: istock nop.rcni.com To subscribe contact:

3 Introduction The demands on health and social care have never been greater. Healthcare professionals work in a complex landscape, with resource-strapped services and frequent reports that highlight the variable quality of care experiences. As a result, it is vital to consider how service partnerships can be improved to provide a better future for some of the most vulnerable people in society. There are 240,000 people in care homes in the UK, and it is estimated that 70% of residents have dementia (NHS England (NHSE) 2014). The age of the resident population means that most will have a range of comorbidities and this affects how care can, and should be, delivered. In contrast, 40% of people over the age of 65 occupying a hospital bed will be living with dementia (Alzheimer s Society (AS) 2014). Improving care is more than a monetary issue; equal focus should be given to the input of healthcare professionals and support for them to improve their work. The care home sector and the NHS must work together to ensure best outcomes through timely interventions. Acute-care hospital admissions should only be seen as a last resort when community care is considered unsafe or unable to meet the individual s needs. Maximising wellbeing, early intervention and prompt input from experts can improve health outcomes and prevent unnecessary admissions. When taking part in advance-care planning, professionals should share information and knowledge about the person, and take into account his or her expressed wishes. The interface between hospitals and care homes is an important one as people s care can traverse between settings and across systems. An ageing population means that frailty is one part of the complex clinical picture for those living in a supported care environment, and its effects will at times require interventions across hospital settings and within primary care. People living with dementia also live with multiple comorbidities that require intervention and, at times, acute management. This can create a challenge to those caring for them, as can the management of any presenting symptoms. There is rising demand on acute care services, so appropriate and timely admission, and expedient discharge, are vital. A prolonged and unnecessary hospital stay can have a negative impact on the person and his or her family. NHS England published its Five Year Forward View in 2014 (NHSE 2014) and has committed to collaborate with care homes to improve care and system management. Meanwhile, the Care Quality Commission (CQC) published a report on the care home and hospital interface for people with dementia (CQC 2014). Cracks in the Pathway In 2014 the CQC undertook a thematic review to look at how hospitals and care homes worked together to support people living with dementia. The interface of these services is critical and the review highlighted areas of good and poor practice (CQC 2014). Learning lessons from this can help to create a blueprint for change to improve the care experience and the management of care NURSING OLDER PEOPLE/RCNi June ::

4 ESSENTIAL GUIDE The interface between care homes and hospitals: dementia in both settings, and embed best practice in supporting people living with dementia to receive appropriate care. Fundamental to getting it right is the need for better understanding between the NHS and care home sector. The outdated view that care homes are places of genteel retirement is still prevalent; in reality, complex nursing takes place in these care settings, often with few registered nurses and poor clinical support. There is urgent need for an equitable and timely response by NHS services, both in primary and secondary care, and a professional dialogue that recognises the skill and expertise of the care home workforce in managing people with multiple complex needs in collaboration with the person and his or her family. The CQC s report, Cracks in the Pathway (CQC 2014), found that in 90% of care homes and hospitals visited, aspects of variable or poor care were identified. The findings can be broken down as follows: Assessment of care needs In 29% of care homes and 56% of hospitals there were aspects of variable or poor care regarding how a person s needs were assessed. Planning and delivery of care In 34% of care homes and 42% of hospitals there were aspects of variable or poor care regarding people s physical, mental and emotional health, and their social care needs. Providers working together In 27% of care homes and 22% of hospitals there were aspects of variable or poor care regarding arrangements for how information was shared when people moved between services. Involvement In 33% of care homes and 61% of hospitals, there was variable or poor care regarding people, or their families and carers, not being involved in decisions about their care or choices about how to spend their time. Staffing In 27% of care homes and 56% of hospitals there was variable or poor care regarding staff s understanding and knowledge of dementia. Monitoring the quality of care In 37% of care homes and 28% of hospitals there were aspects of variable or poor practice in the way providers monitored the quality of dementia care. The NHS Five Year Forward View In 2014 NHS England published The NHS Five Year Forward View document which, for the first time, set out how it wanted care homes and the NHS to work together. This was underpinned by the British Geriatrics Society s (BGS) Quest for Quality report (BGS 2011), which championed the need for care homes to be better served by the NHS and assured equal access to the right care at the right time. The opportunity created by the Better Care Fund, announced by the government in 2013, means that strong community-based support can be established to help people avoid admission into long-term care or to remain as independent as possible for as long as they can, and improve their quality of life. The NHS must take a fresh approach to managing frailty and increase chances for early intervention to prevent unnecessary deterioration and unacceptable extended hospital stays. Creative care can make a big difference, minimising the distress of being looked after by unfamiliar people in an alien and intimidating environment, such as a hospital. 4 June :: 2015 NURSING OLDER PEOPLE/RCNi

5 Case study: Peninsula Community Health Residents in care homes have complex healthcare needs, which can include multiple long-term conditions, significant disability and frailty. All have some disability, and most have dementia and high rates of both primary care consultation and hospital admission. In Cornwall we have several care homes and a high number of acute admissions to secondary care. The existing model of healthcare provision, with ad hoc support using primary care resources, inadequately met individuals needs. In February 2012 a nurse practitioner for care homes (NPCH) began a six-month project with Peninsula Community Health homes to reduce avoidable admissions. Following the success of the project, NHS Kernow commissioned two NPCHs through our company to work with selected care homes. Peninsula s role is to reduce avoidable acute admissions to secondary care, while also supporting, coaching and developing staff to address clinical needs, with a focus on complex comorbidities and frailty. This requires a structured and proactive approach to care, promoting the minimisation of predictable acute events such as falls, and urinary and chest infections, as well as providing advance end of life care planning. The NPCHs visit patients homes once a month, often with the dementia liaison and community nurses, to undertake clinical frailty assessments. This helps to prioritise individuals for medical and medication reviews and to initiate comprehensive older people assessments. All acute admissions are reviewed as part of a root cause analysis to investigate the reasons for admission, and then strategies are implemented to reduce the risk of avoidable admissions in the future. Once clinical risks and issues have been identified and assessed, the NPCH directs and implements robust and specific clinical management plans. These are condition-specific, advising on how to keep the person well and identify and act on early symptom changes. The NPCHs also help to inform and develop services and systems that interface with the care homes. This includes supporting the creation of new contracts and guidelines with nursing homes, launching and participating in a countywide care home collaborative and producing an intermediate admissions pathway and assessment tool. As part of their role to improve quality care, the NPCHs spend a significant amount of time on service improvement and safeguarding strategies using a multidisciplinary approach. Countywide admissions have been cut as a result of the NPCHs interventions, with a significant reduction particularly in the care homes they have been working with. These homes report greater confidence in dealing with clinical changes and can now act faster to prevent deterioration and avoid admission. There are still whole-system challenges, and the service is only available to certain homes at present, but health plans such as the NHS Five Year Forward View are identifying the need for models of enhanced health care in all care homes. This may enable the expansion of services that target the complex needs of this vulnerable population. Marie Prior, nurse practitioner, Peninsula Community Health marie.prior@pch-cic.nhs.uk Case study: St Christopher s Hospice The care home support team help staff to develop their end of life care practice, involving residents and their families in choices and NURSING OLDER PEOPLE/RCNi June ::

6 ESSENTIAL GUIDE The interface between care homes and hospitals: dementia decisions about their care. We provide support, education and training on how to talk to residents and their families about end of life care, death and dying, and how to carry out advance-care planning symptom management especially pain care of the dying person and bereavement support for families and friends. We encourage care homes to embed palliative care principles into their daily routines by introducing systems of working that enable them to: Identify residents in their last year of life. Develop good working relations with the multiprofessional team, such as GPs, community nurses and their local palliative care nurse. Plan ahead with residents and their families and friends. Anticipate potential difficulties. Put strategies in place and support their staff through the emotional experience of caring for people who are dying. We are a regional training centre for the Gold Standard Framework in Care Homes programme (GSFCH) and run this scheme yearly. This nationally recognised accreditation programme helps nursing home staff to implement excellent end of life care, through good systems and processes, staff support and education. The care home support team also helps residential and nursing homes to participate in another programme Steps to Success. These two programmes have led to greater staff confidence and competence in providing end of life care. We also run a sustainability scheme to help the homes maintain and develop their skills and knowledge. The scheme introduces new staff to palliative care and supports the end of life care practice of staff who have been through the GSFCH programme. We aim to ensure that everyone keeps their learning up to date and develops their end of life care practice. Team members have two roles: advancing practice development together with clinical consultancy work. As well as running the education programmes, some team members visit the care homes to develop a palliative care model that covers difficult conversations, advance-care planning, pain assessment and symptom management. Clinically, we provide individual specialist palliative care for people with complex needs. The team also helps to disseminate Coordinate My Care (CMC) training and practice to nursing homes in Lewisham, Lambeth, Southwark, Bromley and Croydon. CMC is a pan-london NHS initiative that enables personalised urgent care plans to be shared electronically. Confidential information is shared with bodies such as ambulance and out-of-hours GP services to support a sensitive response in emergencies. Locally, we are the link between nursing homes and CMC. We coordinate the Family Perception of Care, an internal audit process, ensuring that questionnaires are sent to bereaved relatives three months after a care home resident s death, and analysing the responses. This provides a measure of the quality of care given to residents who have died in care homes across all the clinical commissioning groups that St Christopher s serves. The results are fed back to participating care homes, and action plans are developed with individual homes to help them improve their end of life care. We keep a record of where care home residents die, as well as the use of end of life care tools by care home staff. This gives us an idea of whether we and the homes are achieving our aims and helping people to die in their place of choice. We have been active in research with care homes, including: a cluster randomised 6 June :: 2015 NURSING OLDER PEOPLE/RCNi

7 controlled trial examining the effect of different models of facilitation when implementing the GSFCH programme; and a mixed methods study looking at how the programme was facilitated for advance-care planning in end of life care in nursing homes. Further research is planned to develop the work of the team. Julie Kinley, nurse consultant, care homes, St Christopher s Hospice j.kinley@stchristophers.org.uk Case study: Cumbria Partnership Trust CHESS (Care Home Education and Support Service) was established in Cumbria to improve the wellbeing of older people with mental health needs. The service aims to develop an approach grounded firmly in values of person-centred care and recovery, while remaining flexible enough to reflect clients changing needs. It aspired to be collaborative, evidence based and future focused. Before CHESS was developed, there was a higher admission rate of older people with mental health needs from care homes (52%) and, in addition, a high re-admission rate of people discharged to care homes who then found that they could not manage (20%). Everybody s Business (Department of Health (DH) 2005) describes key components of a modern older people s mental health service. With reference to care in residential settings, the document says workforce development is crucial and that given the very high occurrence of mental health problems in non-specialist care, and the significant skills required to provide good quality person-centred care, staff require training and support in what can be an emotionally challenging area of work. The mental health needs of people living in care homes are extensive and generally not well met. Up to 70% of residents in nonspecialist care homes for older people have dementia and the prevalence rises to between 90% and 95% in homes for the elderly mentally infirm. Also, an estimated 50% of all care home residents have depressive disorders that would warrant intervention (AS 2014). Behavioural disturbance in dementia in these settings is common and can cause stress in residents and staff. The philosophy of the CHESS service is illustrated by its logo that comprises chess pieces and develops the analogy that the initial position of a person is like that of a pawn in the game, with little influence on the outcome of who wins. The vision of CHESS is that the person becomes king and that the other pieces in the game then work together to protect the king throughout the recovery journey. The CHESS team has established a service to address these issues and improve support given to care homes. Evidence on the reduction of carer s strain suggests education alone is not effective; however, education combined with specialist input and support enables greater skills growth in carers. To reflect this, CHESS has developed two approaches a rolling programme of mental health education and an outreach service. The key areas of focus for these are: Dementia awareness. Person-centred care. Understanding behaviour and behaviour that challenges others. Life history and wellbeing. Occupation and meaningful activity. Falls, pain management, catheter care and nutrition. Environmental factors and cognitive stimulation. Acute confusion and delirium. Understanding and recognising depression. NURSING OLDER PEOPLE/RCNi June ::

8 ESSENTIAL GUIDE The interface between care homes and hospitals: dementia Medication. Understanding psychotic experiences and recovery. The team comprises a number of members including liaison nurses and outreach support workers. They play a vital role in specialist assessment, time-limited interventions and facilitation of discharge to care homes from the NHS. Work alongside care home staff backs up learning with practical support; a core component of this is internal liaison with other community mental health teams/chess colleagues when needed. The team supports care homes to meet the requirements of residents and enhance the lives of older people with mental health needs. When a client on an inpatient ward is being considered for placement in a care home and continued follow up is required, or if a particular behaviour management plan is in place, the CHESS outreach service will become involved in the discharge at an early stage. The team s staff will work on the ward, getting to know clients and their carers, and implement individualised recovery care plans. When people are discharged to the care home, the CHESS staff will follow their progress, providing a familiar face as well as working collaboratively with care home staff to pass on behavioural interventions. Collaborative work with care home staff is fundamental to the operation of the service. Such integrated working allows for the development and implementation of structured, individual care plans that promote recovery, maximise independence and optimise the meeting of mental health needs. Active engagement strategies and early-signs monitoring aim to identify any potential crisis at an early stage, with specific crisis-management plans drawn up to manage problems effectively. The CHESS team work with care home staff to back up the knowledge gained through education. The CHESS approach has seen demonstrable success: Before the CHESS intervention Admissions to inpatient service from care homes = 52%. Re-admissions to inpatient service from care homes = 20%. After the CHESS intervention Admissions to inpatient services from care homes = 5%. Re-admissions to inpatient service from care homes = 3%. The service continues to thrive and change to meet increasing demand for specialist support. David Storm is senior clinical manager David.storm@cumbria.nhs.uk Case study: Care Home Assessment Team, Enfield Community Services The Care Home Assessment Team (CHAT) was set up in January 2012 to address the needs of residents living in care homes across the borough. It is hosted by Barnet, Enfield and Haringey Mental Health Trust, and was commissioned by Enfield Clinical Commissioning Group. The team s success has led to the recent expansion of the service and this has been well received by our care home partners. We practice across 31 homes, supporting people over 65 years of age in residential and nursing care. We plan to expand further to cover all eligible care homes in the near future. The team is multidisciplinary and is supported by consultant geriatricians, community matrons, healthcare assistants and a phlebotomist. The team aims to 8 June :: 2015 NURSING OLDER PEOPLE/RCNi

9 improve access to health care where needed and facilitate integration between primary and secondary care. Integral to our approach is building partnerships with primary and secondary clinical services to enhance the service and ensure best outcomes. Sharing information and skills helps to support our patients and improve their quality of care. Early intervention is vital and we want to identify problems at a point when clients can have swift and appropriate clinical intervention to prevent unnecessary admission to the acute hospital, and to reduce the need for multiple GP call outs. CHAT provides five key services to our care home partners: Rapid access telephone advice A Monday-to- Friday telephone support line. This is managed by the community matron or consultant geriatrician, and offers advice and rapid assessment of medical problems for acutely unwell residents. All urgent cases are seen within four hours. Rolling review A comprehensive geriatric assessment for all frail residents with multiple pathologies and complex care needs. All new residents to care homes are seen within two weeks, along with residents discharged from hospital. The review addresses continuity of management of long-term conditions, as well as resolving frequent and common conditions such as constipation and pain. We also advise on other key conditions and best clinical practice, such as falls prevention, and identify residents who would benefit from advance-care planning. Our review of medication service reduces incidents of polypharmacy and inappropriate antipsychotic medication, and can help with pain management and alternative behavioural management techniques. End of life care Working with colleagues, we aim to improve access to better end of life and palliative care, as well as teaching staff about best practice at the end of life. Care planning Through better care management we can ensure that residents receive care at home, which will avoid hospital admissions at the end of their life. Staff development in care homes We provide learning on a number of key topics for home-based staff, including dementia care, medication management, falls prevention, wound care, nutrition and dysphagia. Melanie Pettitt is nurse practitioner, care homes Admin m.pettitt@nhs.net Southern Health and Social Care Trust The trust has around 1,600 older people in care homes, most of which are run by organisations in the independent sector. In 2014, the trust developed a new service model to support care delivery to older residents, and to monitor and review placements and quality of care. This service is delivered by the Care Home Support Team (CHST), which is led by the trust s nurse consultant for older people. The CHST is an integrated team that supports the care of older people, including those with memory problems who are permanent residents in care homes, in partnership with staff from the home. The team comprises: Nurses. Social workers. An occupational therapist (OT). NURSING OLDER PEOPLE/RCNi June ::

10 ESSENTIAL GUIDE The interface between care homes and hospitals: dementia Older people s specialists nurses. Adult safeguarding, social work and nursing practitioners. The team takes a lead role in: Care reviews. Contract reviews. Specialist nursing support and guidance. Assessing and reviewing complex equipment needs. Investigation of incidents. Adult safeguarding investigations. Leading performance management processes, such as contract compliance and the investigation of complaints. Key workers are aligned to homes and are the core contact for the older residents placed by the trust. In addition, each home has an aligned older person s specialist nurse and OT. As older people in care homes have complex care needs and comorbidities, the key workers also review the nursing care and refer to other members of the team or to specialist community teams for further assessment and advice. While this is a relatively new service, staff have found that this is a more personcentred approach to supporting residents and care home managers. The trust runs a forum with the managers that aims to improve practice and facilitate seminars on topics of interest such as seating provision, falls and palliative care. Recent examples of partnership working include the development of a falls toolkit and sample falls policy, a care home admission form for hospital admissions, and an advocacy toolkit. References Alzheimer s Society (2014) Dementia UK: Update. AS, London. org.uk/dementiauk British Geriatrics Society (2011) Quest for Quality. BGS, London. tinyurl. com/5wgxmpt Care Quality Commission (2014) Cracks in the Pathway. CQC, London. tinyurl.com/qhfpdce Jane Greene is nurse consultant for older people jane.greene@southerntrust.hscni.net Conclusion There is much to be commended where health and social care work together to deliver optimal care. A respect for the contribution that each other makes is paramount in trusting the professional relationship between sectors, minimising repetition and workload, and providing a platform to build a better system. This work is underpinned by shared values where professional autonomy and integrity is trusted between care homes and hospitals, and information is exchanged with honesty. The emerging models of collaborative work lead the way to more effective partnerships and, most importantly, delivery of the best care by the best people in the best place. By the end of 2015 there will be an estimated 1 million people living with dementia in the UK (AS 2014). Undoubtedly this will mean that the 40% of people in hospitals living with dementia will double. A professional healthcare workforce for the future must be well trained, with the best skills, to ensure appropriate management of people presenting with acute illness within the context of an underlying diagnosis of dementia. The Cracks in the Pathway will need to be not only covered over, but also replaced by a new route to ease transition and flow across the health and social care landscape. Department of Health (2005) Everybody s Business: Integrated Mental Health Services for Older Adults A Service Development Guide. DH, London. NHS England (2014) The NHS Five Year Forward View. NHSE, London. ourwork/futurenhs 10 June :: 2015 NURSING OLDER PEOPLE/RCNi

11 Resources Age UK Alzheimer s Society British Geriatrics Society Care England Care Quality Commission Dementia Action Alliance Dementia Pledge NHS Confederation NHS England s Five Year Forward View Royal College of Nursing tinyurl.com/ll2o7du Social Care Institute for Excellence tinyurl.com/ygez66n NURSING OLDER PEOPLE/RCNi June ::

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