SERVICE FRAMEWORK FOR OLDER PEOPLE

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1 SERVICE FRAMEWORK FOR OLDER PEOPLE

2 TABLE of CONTENTS SECTION STANDARD TITLE Page No Foreword 4 Summary of Standards 6 1 Introduction to Service Frameworks 36 2 The Service Framework for Older People 42 3 PERSON CENTRED CARE 52 1 Engagement and Choice 54 2 Equality of Opportunity and Eliminating 58 Discrimination 3 Communication (Generic) 61 4 Involvement (Generic) 63 5 Advocacy 66 6 Independent Advocacy (Generic) 69 4 HEALTH AND SOCIAL WELLBEING 73 IMPROVEMENT 7 Healthy Ageing 75 8 Nutrition in Older People 80 9 Healthy Eating (Generic) Smoking (Generic) Alcohol (Generic) Activity (Generic) Prevention of Falls Social Inclusion and Quality of Life SAFEGUARDING Raising Public Awareness Accessing Services to Safeguard 110 Older People 17 Responding to Older People who are at Risk Development of Protection Plans Safeguarding People (Generic) CARERS Identifying and Supporting Carers (Generic) Identification and Recognition of Carers Information for Carers Financial Advice and Information for Carers Flexible, Responsive Services Respite for Carers Carer Health and Well-Being 151 1

3 27 Involving Carers CONDITIONS MORE COMMON IN OLDER 158 PEOPLE 28 Falls Screening in Primary Care Falls Presenting to Intermediate or Secondary 164 Care 30 Hospital Care of Older People with a 168 Fracture 31 Continence Services for Older People Recognition and Prevention of 175 Delirium 33 Management of Delirium End of Life Care Planning for Older People with 182 Advanced Dementia 35 Immobility MEDICINES MANAGEMENT Medicines Management Medicines Review TRANSITIONS OF CARE Single Access Point for Information and 200 Services. 39 Re-ablement to Maintain Independence Early Identification to Maximise 206 Independence 41 Increased Awareness of Needs in General 210 Hospitals 42 Improved Access to Assessment and 214 Rehabilitation 43 Specialist Support in Nursing Homes Person-centred Palliative and End of Life 220 Care 45 Palliative and End of Life Care (Generic) Improved Dementia and Mental Health Services 228 2

4 Annex A List of Service Frameworks 232 Annex B Glossary of Terms Used 233 Annex C Abbreviations 239 Annex D Project Team 240 Annex E Membership of Older People s Reference Group 242 Annex F Membership of Sub Groups 243 Annex G Comments and Recommendations from the Older 250 Peoples Reference Group Annex H Summary of the Report of the Older Peoples Service 252 Framework Reference Group Annex I Legislative and Policy Context 257 3

5 Foreword As Minister for Health, Social Services and Public Safety I am determined to ensure that services are safe, improve health and wellbeing of individuals and communities and, at the same time, make the best use of available resources. In addition, I believe it is important that services, as far as possible, meet the needs and preferences of people and are accessible to all regardless of where they live or who they are. To make this happen, my Department has started work on the development of a set of Service Frameworks which set out explicit standards for health and social care to be used by patients, clients, carers and their wider families to help them understand the standard of care they can expect to receive. These Frameworks will also be used by health and social care organisations in planning and delivering services. The first group of Frameworks focus on the most significant causes of ill health and disability in Northern Ireland cardiovascular disease, respiratory disease, cancer, mental health and learning disability. In addition to the Service Framework for Older People, work has also commenced to develop a Service Framework for Children and Young People. The Service Framework for Older People sets standards in relation to people over 65 whilst taking account of the needs of those over 50, where appropriate, particularly in relation to preventative measures. The standards relate to Person-centred Care; Health and Social Wellbeing Improvement; Safeguarding; Carers; Conditions more Common in Older People; Medicines Management and Transitions of Care. Each standard is supported by levels of performance to be achieved over 3 years and the Framework will be subject to regular review and refinement in the light of new evidence. This will ensure that it provides a sound basis for continued improvement in the quality of health and social services. The development of this Framework has been an inclusive process involving people from all aspects of health and social care, patients, clients and carers, all of whose support has been invaluable. 4

6 The application of the standards set out in this Framework has the potential to transform the quality of service provision for older people. Edwin Poots MLA Minister for Health, Social Services and Public Safety 5

7 SUMMARY of STANDARDS PERSON CENTRED CARE STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 1: All older people should be treated as individuals, be enabled to engage fully in making informed choices about their own care / treatment and have control over the way in which it is delivered. Standard 2: All older people should expect the same opportunity of access to assessment, care and treatment as other users of health and social care services. 1. Trusts will have a Person-centred Care Module as part of Corporate Induction Training. 2. Assessment of need and care planning is developed collaboratively between staff and older people on a multi-disciplinary basis. 3. Older people receive support / services to meet their individual needs at the right time. 1.Older people experience equal access to assessment, care and treatment. 2. Review of Trusts Equality Policies that safeguard and promote Human Rights. All Trusts. March 2015 (end of Year 1) Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline March 2015 (end of Year 1) Performance level set once baseline is established. All Trusts March 2015 (end of Year 1) 6

8 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 3 (Generic): All patients, clients, carers and the public should be engaged through effective communications by all organisations delivering health and social care. 1. Percentage of patients and clients expressing satisfaction with communication Establish baseline and set target March 2014 Report percentage increase of patient and client satisfaction with communication March 2015 Report percentage increase of patient and client satisfaction with communication March 2016 Standard 4 (Generic): All patients, clients, carers and the public should have opportunities to be actively involved in the planning, delivery and monitoring of health and social care at all levels. 1. Percentage of job descriptions containing PPI as responsibility Year 1: senior and middle management Year 2: designated PPI leads at all levels of HSC organisations Year 3: all new job descriptions Establish baseline and set target March 2014 Monitor progress March % - in all new job descriptions March Percentage of patients and clients expressing satisfaction Establish baseline and set target March 2014 Report percentage increase of patient and client satisfaction March 2015 Report percentage increase of patient and client satisfaction March

9 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 4:(continued) 3.Percentage of staff who have gained PPI training (details to be agreed for 2014/2015) Conduct training needs assessment for PPI, commission design of PPI training programme (March 2014) Establish baseline and set target March Standard 5: All older people should have access to independent advocacy that provides information, advice and support to enable them to make informed choices and be fully involved in decisions affecting them. 1. Each Trust has at least one Service Level Agreement with the voluntary or community sector to provide information, advice and advocacy services. 2. Increased awareness among older people of the role and function of advocacy. Monitor percentage of staff trained at different levels in PPI March 2016 All Trusts. March 2015 (end of Year 1) Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Standard 6 (Generic): Users of health and social care services and their carers should have access to independent advocacy as required. 1. To be determined. To be determined 8

10 HEALTH AND SOCIAL WELL BEING IMPROVEMENT STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 7: All older people should have access to evidence based health and wellbeing advice, information, programmes and services that are tailored to address their specific and varied health and wellbeing needs across their life course. 1. Board and PHA review of current services for older people to ensure that their health and wellbeing needs are identified and inform service change. 2. Trusts review of their coordination of the development and delivery of multifaceted health and wellbeing programmes and services to address the wider health and wellbeing needs of older people. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Standard 8: All older people should be supported to achieve optimum nutritional health and to maintain a healthy body weight. 3. Trusts detailing the provision of appropriate assessment, advice and information on all aspects of health and wellbeing. Mechanisms should be in place to effectively signpost/refer older people to multi sectoral services and support. 1. The Board/PHA s review of the current services addressing the nutritional needs of older people and ensure interventions are in place to promote healthy eating and identify and address individuals at risk of malnutrition. 60% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 90% March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 9

11 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 8: (continued) 2. Trusts reports showing that older people within their care have access to and are adequately supported to maintain a healthy and well balanced diet. All Trusts March 2015 (end of Year 1) and ongoing. Standard 9 (Generic): All HSC staff, as appropriate, should provide people with healthy eating support and guidance according to their needs. 3. Number of older people and, where appropriate their carers have access to a comprehensive range of health information, advice and support services/ programmes to maintain and improve their nutritional and oral health. 4. Number of older people in acute, residential or nursing homes, or in receipt of a community care package who have access to oral health screening and appropriate dental treatment and care. 1. Percentage of people eating the recommended 5 portions of fruit or vegetables each day. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Baseline for 2011/12 = 32% overall, 26% for males and 36% for females Target: maintain or at best increase percentage by 1% year on year 10

12 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 10 (Generic): All HSC staff, as appropriate, should advise people who smoke of the risks associated with smoking and signpost them to well-developed specialist smoking cessation services. 1. Number of people who are accessing Stop Smoking Services 2. Proportion of the smoking population who are accessing Stop Smoking Services. Baseline 2011/12 = % year on year increase (March ) Baseline 2011/12 =10.8%. NICE guidance and the ten year tobacco strategy call for a target of over 5% of the smoking population to be reached, hence target to maintain at >/= 5% (March ) 3. Number of people using stop smoking services who have quit at 4 weeks and 52 weeks. Baseline 2011/12 = 20,299 for those quit at 4 weeks and 5,889 for those quit at 52 weeks. Target 4% increase in respective numbers year on year. (March ) Standard 11 (Generic): All HSC staff, as appropriate, should provide support and advice on recommended levels of alcohol consumption. 1. Percentage of people who receive screening in primary care settings in relation to their alcohol consumption. Establish baseline March 2014 Performance level to be determined once baseline established March

13 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 12 (Generic): All HSC staff, as appropriate, should provide support and advice on recommended levels of physical activity. 1. Percentage of people meeting the recommended level of physical activity per week. New physical activity guidelines were launched in 2011 and as such a new suite of questions to establish the percentage of people of people meeting the recommended level of physical activity per week has been integrated within the 2012/13 Northern Ireland Health Survey. It is anticipated these new baseline results will be available in Nov / Dec March 2014 Performance level to be agreed thereafter Standard 13: Older people should be informed of the factors which increase risk of fragility fractures as a result of osteoporosis or reduced bone strength. and be able to access interventions to reduce the risk. 1. Health and Social Care Board s/public Health Agency s review of the current provision of falls prevention services to ensure the provision of comprehensive, evidence based falls prevention services for all older people. 2.Trust Report detailing the provision of coordinated Falls Services that increase awareness of the ways to prevent and reduce the risk of falling, provide falls prevention programmes that have reduced the risk of older people falling, including strength and balance training and offer services to reduce the impact of falls. All Trusts March 2015 (end of Year 1) and ongoing. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 12

14 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 13: (continued) 3.Trusts will ensure the provision of coordinated, community based health and wellbeing services and programmes that seek to reduce the risk of falling by increasing physical activity, maintaining a healthy diet, ensuring regular vision checks, stopping smoking, reducing alcohol intake, maintaining safe homes and neighbourhood environments. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 4. Older people in contact with health and social care services are routinely asked whether they have fallen in the past year, have their risk of falling assessed and provided with appropriate advice, support and signposting to services to address their specific needs. 5. All nursing homes that have been contracted by Health and Social Care Trusts will have in place actions to reduce the risk and impact of falling by residents. 60% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 90% March 2017(end of Year 3) Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 6. All older people, who have a fall and call for an ambulance, are placed on an appropriate pathway for assessment and intervention. Establish baseline March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. 13

15 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 14: All older people will be supported to maintain their mental health and wellbeing, quality of life and independence as they grow older. 1. Health and Social Care Board s/public Health Agency s review of the current provision of services to address the mental health and social wellbeing needs of older people and ensure effective multi-sectoral approaches are developed and maintained to address the wider social determinants and impact of social isolation. All Trusts. March 2015 (end of Year 1) and ongoing. 2. Health and Social Care Trusts coordination, development and delivery of multifaceted services and programmes with local partners to address the wider mental health and social wellbeing needs of older people and their carers. 3. All older people in contact with services have access to appropriate assessment of their wider health and well-being needs and signposting to further help and support as required. All Trusts. March 2015 (end of Year 1) and ongoing. 60% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 100% March 2017 (end of Year 3) 14

16 SAFEGUARDING STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 15: Health and social care organisations must work together to prevent the abuse or exploitation of older people by raising public awareness and developing a clear message that such abuse is unacceptable and will not be tolerated. 1. Northern Ireland Adult Safeguarding Partnership s (NIASP) Strategic Plan and Annual Action Plans to include a prevention plan. 2. Local Adult Safeguarding Partnerships (LASPs) Safeguarding Plan and annual Action Plans to include a local prevention plan. 3. Delivery of at least one Peer Educator training programme for older people in each Trust area. All Trusts. March 2015 (end of Year 1) and ongoing. All Trusts. March 2015 (end of Year 1) and ongoing. All Trusts. March 2016 (end of Year 2) and ongoing Standard 16: Health and social care professionals should work with older people, their carers and relevant others to recognise situations of abuse, or exploitation and to access services to safeguard vulnerable people. 1. NIASP Strategy and associated Annual Action Plans will include the development, implementation and review of standardised regional thresholds for access to adult safeguarding services to improve consistency of screening and decision making. 2. Each LASP Safeguarding Plan and associated annual Action Plans will include clear signposting of services and standardised regional thresholds for access to adults safeguarding services, All Trusts. March 2015 (end of Year 1) and ongoing All Trusts March 2015 (end of Year 1) and ongoing 15

17 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 16: (continued) improve consistency of screening and decision making. 3. Each provider organisation ensures that information on how to access safeguarding services is available to service users and their carers. 4. Each provider organisation ensures that all staff members receive appropriate training on how to recognise abuse and access safeguarding services. 5. Establishment of at least one Peer Advocacy service to support people through the process of disclosure of abuse, exploitation, or neglect in each Trust area. 6. Number of service users where potential abuse is identified at initial assessment as % of referrals to safeguarding services. 80% March 2015 (end of Year 1) and ongoing 80% March 2015 (end of Year 1) and ongoing All Trusts. March 2016 (end of Year 2) and ongoing Establish baseline. March 2016 (end of Year 2) and ongoing Performance level set once baseline is established. 16

18 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 17: Health and social care organisations that receive a report that an individual has been, or may be experiencing abuse or neglect will respond in a positive, timely and proactive manner. 1. NIASP will ensure that all regional adult safeguarding procedures include timescales for responding to allegations of abuse. 2. Local Adult Safeguarding Plans will ensure local safeguarding services comply with timescales for responding to allegations of abuse. All Trusts. March 2015 (end of Year 1) and ongoing Establish baseline. March 2016 (end of Year 2) and ongoing Performance level set once baseline is established. Standard 18: Health and social care organisations will work in partnership with service users, their carers and/or representatives and other relevant agencies so that any Protection Plan is tailored to meet the needs of the older person. 3. Service users are enabled to exercise choice and control whenever possible in relation to the management of allegations of abuse. 4. Percentage of older people who have not had a NISAT specialist risk assessment completed which includes a specialist safeguarding assessment is required. 1. NIASP will establish an Adult Safeguarding Forum, which will ensure that users of safeguarding services contribute to the design and commissioning of safeguarding services. 2. Number of people and/or their advocates, who have their need for safeguarding met through their participation in processes such as care Establish baseline. March 2016 (end of Year 2) and ongoing. Performance level set once baseline is established. Establish baseline. March 2016 (end of Year 2) and ongoing Performance level set once baseline is established. 100% March 2016 (end of Year 2) and ongoing Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is 17

19 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 18: (continued) planning, protection planning, case conferences, family group conferences. established. Standard 19 (Generic): All HSC staff should ensure that people of all ages are safeguarded from harm through abuse, exploitation or neglect. 3. Number of Protection Plans in place as a percentage of referrals accepted by Safeguarding Services. 1. All HSC organisations and organisations providing services on behalf of the HSC have a Safeguarding Policy in place, which is effectively aligned with other organisational policies (e.g. recruitment, governance, complaints, SAIs, training, supervision, etc.) The Safeguarding Policy is supported by robust procedures and guidelines. 2. All HSC organisations and organisations providing services on behalf of the HSC have Safeguarding Plans in place. 3. All HSC organisations and organisations providing services on behalf of the HSC have Safeguarding champions in place in order to promote awareness of safeguarding issues in their workplace. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline - March 2014 Performance level to be determined once baseline established Establish baseline - March 2014 Performance level to be determined once baseline established Establish baseline - March 2014 Performance level to be determined once baseline established 18

20 CARERS STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 20 (Generic): All HSC staff should identify carers (whether they are parents, family members, siblings or friends) at the earliest opportunity to work in partnership with them and to ensure that they have effective support as needed. 1. Number of front line staff in a range of settings participating in Carer Awareness Training Programmes 2a. The number of carers who are offered Carers Assessments 2b. The percentage of carers who participate in Carers Assessments 20% March % March 2016 Improvement targets set by HSCB in conjunction with Carers Strategy Implementation Group. Reviewed annually Improvement targets set by HSCB in conjunction with Carers Strategy Implementation Group. Reviewed annually Standard 21: Older carers and carers of older people should be identified at the earliest opportunity, by all staff in relevant organisations working together, to improve awareness and recognition of the carer s role in a range of settings. 1a. The number of carers who are identified by GP practices. 1b. The percentage of carers who have been referred for support by their GP. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 19

21 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard No 22: Older carers and carers of older people will be offered information to support them in making choices and throughout their caring journey. This should be tailored to individual need, accurate, accessible and appropriate. 1a Health and Social Care Trusts will produce a local information pack for carers (complementary to the DHSSPS Carers A-Z) and information in a range of appropriate formats. 1b Trusts will develop a communication plan to demonstrate how both staff and carers are to be made aware of the available information. 100% March 2015 (end of Year 1) and ongoing. 100% March 2015 (end of Year 1) and ongoing. Standard 23: All carers will be signposted to organisations specialising in benefits and financial advice relevant to their role, as early as possible to minimise the impact of caring on their standard of living. 1. Number of carers known to Trusts who have been signposted for financial advice. 2. Feedback from a sample of carers about their experiences regarding financial issues. Establish baseline. March 2015 (end of Year 1) and ongoing. Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 20

22 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 24: Older carers and carers of older people will have timely access to flexible and responsive services, in order to meet their individual needs. 1. Number of carers who agreed to being referred for a carers assessment. 2. Number of carers who experience flexible and responsive services to enable them to continue their caring role. 40% March 2015 (end of Year 1) 50% March 2016 (end of Year 2) 60% March 2017 (end of Year 3) 70% March 2015 (end of Year 1) 75% March 2016 (end of Year 2) 80% March 2017 (end of Year 3) Standard 25: Older carers and carers of older people will have timely access to appropriate respite breaks to meet different individual needs and circumstances. 3. Carers level of satisfaction with response to instances of emergency support need. 1a The numbers of carers who have been assessed as requiring respite. 1b. The number of carers who receive respite. Baseline established March 2015 (end of Year 1) Improvement target set and monitored. March 2016 (end of Year 2) Establish baseline. March 2015 (end of Year 1)) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 21

23 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 25: (continued) Standard 26: All older carers and carers of older people will be supported to look after their own physical and emotional health and wellbeing by all relevant organisations. 2. The number of carers who have been assessed as requiring respite and who do not receive respite. 1. The number of carers who participate in health and wellbeing programmes and events for carers. 2. The number of carers who receive training appropriate to individual needs e.g. manual handling, stress management, knowledge about symptoms and potential impacts from the condition of person being cared for. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Set performance level once baseline established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance targets to be set for when baseline established. Standard 27: Older carers and carers of older people should be treated as equal partners. Consequently carers and their representative organisations will be actively involved in the planning, delivery and monitoring of services. 1. Trusts will have an action plan for carer involvement at all levels in their respective organisations. 2. The number of carers actively participating in commissioning, delivery and evaluation of services. 100% March 2015 (end of Year 1) and ongoing. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 22

24 CONDITIONS MORE COMMON IN OLDER PEOPLE STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 28: All older people will be offered annual and opportunistic case-finding checks in Primary Care, to identify individuals at high risk of falling in the future. They will be offered a multi-factorial, evidence based falls and bone health assessment and intervention. Standard 29: All older people presenting to intermediate, or secondary care because of a fall or with an injury resulting from a fall (i.e. fracture) will be offered a multi-factorial, evidencebased falls and bone health assessment and intervention. 1. Staff to assess the agreed range of factors which may cause a person to fall. 2. Individuals identified as at high risk of falling are offered an intervention programme within 4 weeks of index fall 1. Percentage of the total population of older people presenting to intermediate or secondary care because of a fall or with an injury resulting from a fall. 2. Older people presenting to intermediate or secondary care because of a fall are offered a multi factorial, evidence based falls and bone health assessment and intervention within 2 weeks of the index fall. 70% March 2015 (end of Year 1) 80% March 2016 (end of Year 2) 90% March 2017 (end of Year 3) 70% March 2015 (end of Year 1) 80% March 2016 (end of Year 2) 90% March 2017 (end of Year 3) Baseline to be established. March 2015 Performance level set once baseline is established. March 2016 (end of Year 2) March 2017 (end of Year 3) 25% March 2015 (end of Year 1) 50% March 2016 (end of Year 2) 75% March 2017 (end of Year 3) 23

25 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 29: (continued) 3. Older people presenting to intermediate or secondary care because of a fall, or with an injury resulting from a fall will be asked if they were offered a multi-factorial, evidence based falls and bone health assessment and intervention within 2 weeks of the index fall. 25% March 2015 (end of Year 1) 50% March 2016 (end of Year 2) 75% March 2017 (end of Year 3) Standard 30: All older people admitted to an inpatient fracture service should have routine access to acute orthogeriatric medical support from the time of admission 1. Health and Social Care Trusts providing inpatient fracture services have a designated Orthogeriatrician and provide shared care. 2. Older people admitted with a fracture will have a specialist geriatric assessment within 72 hours. 100% March 2015 (end of Year 1) 100% March 2015 (end of Year 1) March 2016 (end of Year 2) March 2017 (end of Year 3) 24

26 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 31: Older people with continence difficulties will have an assessment carried out by a specialist continence health professional and if appropriate receive onward referral to an integrated continence service. 1. Health and Social Care Trusts should have a lead health professional at a senior level responsible for delivery and development of an integrated continence service. 2. Review of Health and Social Care Trusts written policy document for continence promotion and incontinence management. All Trusts Year 1. March 2015 (end of Year 1) All Trusts Year 1. March 2015 (end of Year 1) Integrated Care pathway development. March 2016 (end of Year 2) Integrated Care pathway in place. March 2017 (end of Year 3) 3. Number of older people who have received specialist assessment for continence issues. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 4. Number of older people who have accessed the integrated continence service in each Trust. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. March 2016 (end of Year 2) & March 2017 (end of Year 3) 25

27 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 32: All older people who have a major health crisis should be screened for delirium using a validated assessment tool such as the Confusional Assessment Scale shortened version (CAM). 1. Number of patients who develop delirium in hospital. 2. Reduced length of hospital stay for older people who develop delirium. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 3. Each Health and Social Care Trust will have a Mental Health for Older People Liaison Service to co-ordinate and support the delivery of education and training to front line staff. 4. Number of front line staff in hospitals, domiciliary, residential and nursing homes who have participated in structured training re: assessment and management of delirium. 5. Each Health and Social Care Trust will identify the incidence and prevalence of people who develop delirium. 100% March 2015 (end of Year 1) 20% March 2016 (end of Year 2) 30% March 2017 (end of Year 3) Establish baseline. Annually. 26

28 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 33: All older people should receive a stepped-care approach to the management of delirium. A small minority of people with delirium may require specialist input, or may require to be cared for in a specialised environment. Standard 34: Older people with Advanced Dementia should be identified through existing Primary Care Dementia Registers. These individuals should have the Gold Standards Framework prognostic indicators applied and where appropriate, an End of Life Care Plan should be agreed. 1. Reduction of institutional care as an outcome of an episode of delirium. 2. Reduction in the use of neuroleptic and sedative drugs in the at risk population. 3. Each Health and Social Care Trust will have a Mental Health for Older People Liaison Service to co-ordinate and support the delivery of education and training to front line staff in hospitals, domiciliary care, residential and nursing homes. 1. General Practitioners will identify older people with Advanced Dementia using Gold Standards Framework. 2. General Practitioners will ensure that individuals who have been identified with Advanced Dementia have an Advance Care Plan within 3 months. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 10% March 2015 (end of Year 1) 20% March 2016 (end of Year 2) 30% March 2017 (end of Year 3) 90% March 2015 (end of Year 1) 100% March 2016 (end of Year 2) 27

29 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 35: All older people who present to primary or secondary care with a sudden unexplained deterioration in their mobility should receive a Comprehensive Geriatric Assessment and access to re-enablement services as appropriate. 1.Primary care and ED referral rates to Geriatric Medicine of older people coded as off feet as primary problem. 2.Number of Comprehensive Geriatric Assessments delivered by Trust. 3. Percentage of older people entering institutional care who have received a Comprehensive Geriatric Assessment as part of the Single Assessment Tool prior to permanent placement. Baseline to be established March 2015 (end of Year 1) 100% March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. March 2016 (end of Year 2) & March 2017 (end of Year 3) Baseline to be established March 2015 (end of Year 1) Performance level set once baseline is established. March 2016 (end of Year 2) & March 2017 (end of Year 3) 4. Incidence of pressure sores developed in secondary care settings. Establish baseline. March 2015 (end of Year 1) Reduction in incidence of pressure sores by 30% from baseline March 2016 (end of Year 2) Reduction in incidence of pressure sores by 40% from baseline March 2017 (end of Year 3) 28

30 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 35: (continued) MEDICINES MANAGEMENT 5. Incidence of pressure sores developed in community care settings. Establish baseline March 2015 (end of Year 1) Reduction in incidence of pressure sores by 30% from baseline March 2016 (end of Year 2) Reduction in incidence of pressure sores by 40% from baseline March 2017 (end of Year 3) Standard 36: In partnership with healthcare professionals, older people should be provided with appropriate, safe and effective medicines to enable them to gain maximum benefits from medicines to maintain, or increase their quality and duration of life. 1. Level of prescribing in concordance with local medicines formulary and national standards. 2. Satisfaction reported by people and their carers about medicines information, support for decision making and quality of life. 3. Proportion of people with long term conditions accessing a specific medicines management support programme for concordance. 4. Number of older people with medicines related admissions or re-admissions to hospital. 70% March 2015 (end of Year 1) Ongoing, in tandem with development of the NI formulary. March 2016 (end of Year 2) & March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) Performance levels to be determined once baseline established. Establish baseline. March 2015 (end of Year 1) Performance levels to be determined once baseline established. Establish baseline. March 2017 (end of Year 3) Performance levels to be determined once baseline established. 29

31 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 37: Older people should have a systematic review of all their medicines at appropriate intervals along the patient pathway to ensure that their medicines continue to be appropriate, and that they participate in the treatment as prescribed. 1. Percentage of older people receiving four or more medicines who are offered a medicines review annually. 2. Percentage of older people residing in care homes receiving a face-to-face clinical medicines review annually. 3. Percentage of older people in secondary care, who have had their medicines list checked and verified as accurate on admission. 80% March 2015 (end of Year 1) 80% March 2016 (end of Year 2) 80% March 2017 (end of Year 3) Establish baseline. March 2015 (end of Year 1) Performance levels to be determined once baseline established. Establish baseline. March 2016 (end of Year 2) Performance levels to be determined once baseline established. 4. Review of regional minimum data set arrangements for medicines-related information for use when older people move across care settings is agreed. 5. Medicines with highest risk for older people are monitored appropriately in accordance with local guidance. Progress of arrangements. March 2016 (end of Year 2) Arrangements completed. March 2017 (end of Year 3) Establish baseline. March 2016 (end of Year 2) Performance levels to be determined once baseline established. March 2017 (end of Year 3) 30

32 TRANSITIONS OF CARE STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 38: Older people should be able to access a single point of contact for information and advice about all aspects of community support and health and social care services when they first start to need help to maintain their independence. Standard 39: Older people should be offered a period of reablement to regain their optimum level of independence and confidence before any assessment is made for longer term supports. 1. Number of older people who have accessed the single point of contact and what information, or community support provided. 2. Number of older people who have accessed the single point of contact and required onward referral to health and social care services. 1. Number of older people who no longer require a home care service after a period of re-ablement. 2. Number of older people, who still need a home care service after a period of reablement. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 3. The number of weekly care package hours at the end of re-ablement. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 31

33 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 40: Older people with health problems should be identified early to maximise independence and reduce crisis. Treatment and care should be delivered in the most appropriate setting. 1. Number of older people receiving urgent care at home. 2. Outcomes for older people receiving urgent care at home. Establish baseline. March 2016 (end of Year 2) Performance level set once baseline is established. 100% March 2016 (end of Year 2) Standard 41: Older people with complex needs should be screened and appropriately managed by specialist staff during episodes of general hospital care. 1. Reducing length of hospital stay for older persons with complex needs. 2. Percentage of older people admitted directly to care homes (for the 1 st time from a general hospital). 3.There is a documented discharge plan for each older person with complex needs discharged from a general hospital, including details of communication with the patient, his/her family carer and professionals outside hospital. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 32

34 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 42: Older people with complex health needs including people with Dementia, or mental health needs should be offered comprehensive, specialist assessments and a period of rehabilitation before consideration is given to the need for long term care. 1. Number of people with a comprehensive, person-centred, specialist assessment. 2. Number of older people who accessed rehabilitation programmes. 3. Number of older people who had a comprehensive, person-centred, specialist assessment and period of rehabilitation with the following outcomes: a. returned home with no care package; b. returned home with a care package (please specify number of hours of domiciliary support) c. returned to care home; d. admitted to care home for the first time. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 33

35 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 43: Older people who live in nursing homes should be able to access appropriate medical and other specialist supports to ensure their needs are met safely, effectively including palliative care and end of life care planning. Standard 44: All older people identified to have end of life care needs should have a key worker and access to effective palliative and supportive care services for end of life needs. 1. Number of residents seen by specialist staff in nursing homes. 2. Unscheduled hospital admissions of Care Home residents. 1. Number of patients and family members, or friends who participate in person-centred training to promote optimal health and wellbeing through information, counselling and support for people with end of life care needs. 2. Patient identified to have palliative and end of life care needs allocated a key worker. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. Establish baseline. March 2015 (end of Year 1) Performance level set once baseline is established. 3. Number of older people dying in hospital having been admitted from Nursing Homes. Establish baseline March 2015 (end of Year 1) and ongoing Performance level set once baseline is established. 34

36 STANDARD KEY PERFORMANCE INDICATORS ANTICIPATED PERFORMANCE LEVEL Standard 44: (continued) Standard 45 (Generic): All people with advanced progressive incurable conditions, in conjunction with their carers, should be supported to have their end of life care needs expressed and to die in their preferred place of care 4. All patients identified to have palliative and end of life needs should have the opportunity for holistic assessment and advance care planning. 1. Percentage of the population that is enabled to die in their preferred place of care. 2. Percentage of population with an understanding of advance care planning Performance level set once baseline is established. March 2015 (end of Year 1) Establish baseline March 2014 Performance levels to be determined once baseline established March 2015 Establish baseline March 2014 Performance levels to be determined once baseline established. March 2015 Standard 46: Older people with mental health conditions or dementia should, from an early stage, access services and environments that provide skilled assessment, treatment and care enabling them to maintain as much independence as possible. 1. Trusts should have detailed information on all services for people with mental health conditions including dementia, highlighting linkages, gaps and usage. 2. Trusts should provide detailed information on all services for older people with dementia and mental health conditions. This should show the full continuum of services in community and hospital and include activity and outcomes. This needs to show evidence of shifts towards prevention approaches. 100% March 2015 (end of Year 1) and ongoing. 100% March 2015 (end of Year 1) and ongoing. 35

37 SECTION 1 INTRODUCTION TO SERVICE FRAMEWORKS Background The overall aim of the Department of Health, Social Services and Public Safety (DHSSPS) is to improve the health and social wellbeing of the people of Northern Ireland (NI). In support of this the Department is developing a range of Service Frameworks which set out explicit standards for health and social care that are evidence based and capable of being measured. The first round of Service Frameworks focus on the most significant causes for ill health and disability - cardiovascular health and wellbeing; respiratory health and wellbeing; cancer prevention, treatment and care; mental health and wellbeing; and learning disability. In addition to the Service Framework for Older People, work has also commenced to develop a Service Framework for Children and Young People. See Appendix A Service Frameworks have been identified as a major strand of the reform of health and social care services and provide an opportunity to: strengthen the integration of health and social care services; enhance health and social wellbeing, to include identification of those at risk, and prevent/ protect individuals and local populations from harm and /or disease; promote evidence-informed practice; focus on safe and effective care; and enhance multi-disciplinary and inter-sectoral working. 36

38 Aim of Service Frameworks Service Frameworks will set out the standards of care that service users, their carers and wider family can expect to receive in order to help people to: prevent disease or harm; manage their own health and wellbeing, including understanding how lifestyle affects health and wellbeing including the causes of ill health and its effective management; be aware of what types of treatment and care are available within health and social care; and be clear about the standards of treatment and care they can expect to receive. Service Frameworks will be used by a range of stakeholders including commissioners, statutory and non-statutory providers, and the Regulation and Quality Improvement Authority (RQIA) to commission services, measure performance and monitor care. The Frameworks will identify clear and consistent standards informed by expert advice, research evidence and by national standard setting bodies such as the National Institute for Health and Clinical Excellence (NICE) and the Social Care Institute for Excellence (SCIE). The auditing and measuring of these standards will be assisted by the Guidelines and Implementation Network (GAIN) which will facilitate regional audit linked to priority areas, including Service Frameworks. The standards, in the context of the 10 year Quality Strategy (1), will aim to ensure that health and social care services are: i. Safe health and social care which minimises risk and harm to service users and staff; ii. Effective health and social care that is informed by an evidence base (resulting in improved health and wellbeing outcomes for individuals and communities), is commissioned and delivered in an efficient manner (maximising resource use and avoiding waste), is accessible (is timely, geographically (1) Quality 2020 A 10-Year Quality Strategy for Health and Social Care in Northern Ireland 37

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