GP INFORMATION PACK 100 day Mid Essex Frailty Challenge AND HOW IT LINKS TO THE UNPLANNED ADMISSION DES To provide practices considering joining the challenge with information about what s involved and to share what we have learned to date to improve care for frail people, and to save you time and work!
CONTENTS 01 02 03 04 Key Information The components Stories Next steps + Who s involved + Headlines + Learning so far + Practice commitment and support + Enhanced MDTs + IAM form + Central Point of Access + Community support + Sally + Betty + Derek + Ivy + What s on the horizon + Sign Up! + Flagging and data sharing with MEHT
Key Information + 100 day challenge headlines 01 + Practice commitment + Enhanced MDTs + Case Studies + Practice Support
AGENCIES INVOLVED: GPs supported and facilitated by Nesta the UK s innovation foundation, working with the Rapid Results Institute. Duarte, Inc. 2014 4
KEY CONTACTS Dr Liz Towers: Whitley House Surgery 07712 898065; elizabethtowers@nhs.net Dr Carol Bladen: St Lawrence Medical Practice & Silver End Surgery: 01376 552474 carolbladen@gmail.com Amy Brass: Practice Manager: Whitley House Surgery: 01245 347539 amybrass@nhs.net Gareth Howells: Head of Unplanned Care, Mid Essex CCG: 01245 397656 gareth.howells1@nhs.net
100 DAY CHALLENGE HEADLINES Mid Essex health and social care system is pioneering an innovative approach to radically improve the care for frail individuals and reduce avoidable hospital admissions. The approach brings together commissioners and providers across mid Essex to challenge, empower and support front-line teams to work together and test new approaches and ways of working that achieve measurable improvements in care for frail individuals within 100 day cycles. The first 100 day challenge ran from March-July 2014 and resulted in a significant reduction in avoidable admissions of frail individuals across 7 GP practices. Teams worked together to share ideas and experiences to create a new support model for frail patients in mid Essex. They tested ways to: improve access to the system for patients, families, carers & professionals; improve communication and information sharing within the system; work differently with patients. The project saw the formation of: Enhanced MDTs with greater representation and collaborative working A Single Point of Access for patients and clinicians A patient held care record known as the I.A.M (Information About Me) form The request for weekly data from MEHT tailored to activity which has occurred on identified frail patients The flagging of Frail patients on the hospital system so staff working in A&E can identify them There is also now a Systm One viewer in A&E so that required information can be obtained Now: We want to begin to embed and sustain these changes and we need your help! This pack contains information for you and your practice to consider if you may be interested to sign up to some of the new ways of working and become part of the next wave of the frailty challenge.
WHAT HAVE WE LEARNT? The Headline: We ve achieved significant reductions in unplanned admissions..and The Soft Stuff: Improved responsiveness of health and social care partners to GPs, reducing workload and improving patient experience Improving patient centred care which we are increasingly monitored against by bodies such as NHS England and CQC Health professionals using the I AM form have found it a great and empowering tool to use with patients, their family and carers and much easier to understand and complete than the NHS England DES Care Plan template. The form has facilitated conversations with patients about difficult topics e.g. DNA CPR Enhanced MDTs have vastly improved the relationship between GP Practices and health and social care partners. Representatives from these organisations will provide face to face or written updates on patients they are supporting in time for each Enhanced MDT Increased understanding about the services each organisation provides and when and how to use them to ultimately keep patients in their own care setting Identified patients have access to a Central Point of Access (CPA) they can call instead of the surgery GP Practices can use the same CPA for advice about managing their patients A&E SystmOne viewer for staff to see shared records Weekly MEHT data specifically related to the cohort of patients which compares current activity for that set of patients to the same period 12 months ago. It shows unplanned admissions and A&E attendances Engaging with the voluntary sector in new ways, including through MDTs has allowed patients to be connected with wider community support and activities. Increased understanding and awareness about the support available for patients in the community
PRACTICE COMMITMENT What do we have to do? Assign a champion: This challenge works best if everyone in the practice is engaged, but with an identified lead to maintain momentum and embed new ways of working in the day-to-day work of the practice. This could be a GP, a practice manager or someone else in the practice Have access to support: A number of the existing Challengers have volunteered to be Ambassadors who new practices can call on for advice or support. You would be assigned a pointperson through which to access support - they could attend one of your initial enhanced MDTs for example, or help you to work through any issues that you might come up against (more information below) Broaden out current MDT structure: to develop meaningful joint working relationships across all care settings. This could involve additional organisations supporting frail individuals across the whole system, for example this could include: Mental Health, Community Agents, a named social worker, falls prevention, reablement, pharmacy, updates from MEHT Consider the use of IAM forms as a way to facilitate a new, patient-centred conversation with those you care for. This can also serve as the DES care planning tool (more information below)
PRACTICE SUPPORT What help can I get? Each practice signing up to the frailty challenge will be offered support from a group of ambassadors those involved with the first 100 days of the frailty challenge. You will likely be assigned a point person - this may be a GP, a community matron, a social worker whoever is the best fit given the context of your practice. The group will act as ambassadors for the frailty work. Their role will be two-fold: Informing : As individuals who have experienced the 100 day process and been involved in designing, implementing and refining new solutions, they can offer advice on adopting/adapting new ways of working Trouble shooting : The group will act as your go to people if you have a question, issue or problem to discuss. They will be a proactive link into the system (including primary, secondary care and the voluntary sector). However, importantly, this will be a two way process. We fully expect these new ways of working to continue developing and improving and would be delighted if you would share your stories with us as you adapt and refine these methods in your practices and localities.
What are the different components? + Key principles of approach + Process & key phases + Overview of conditions and support 02
ENHANCED MDT An Enhanced MDT builds on your existing MDT and enhances it by broadening the scope of those who attend and the organisations involved with your patients. This might include: A named social worker to attend GP the practice Mental health representation Falls Prevention Practice managers & surgery staff Community agents (who provide a wealth of knowledge Pharmacist in terms of what is available at the community level from the voluntary sector) And other services as needed e.g. falls prevention, reablement, Community Matrons Patient Centred Named social worker pharmacy etc. District Nurses Community Agents Mental health representation
ENHANCED MDT Hints and Tips It doesn t have to be chaired by a GP or member of the practice in fact, it may work best if it isn t, as we found the MDTs can easily become too clinical. Use your staff! Your nurses and reception staff know so much about your patients use them. Empower them to identify patients they have noticed are struggling, or have had a change in circumstances recently which may make them more vulnerable to admission. We ve found establishing consistent representation from other organisations invited to attend hugely useful in order to establish familiarity and good working relationships. It s important that everyone around the table has a voice, and a supportive atmosphere is created with patients at the centre. With this in place, we have found we can advise one another and provide greater support to each other and the patients considering ways of managing patients we wouldn t have thought about if working individually. Putting in processes for the inevitable instances where people can t attend MDTs has been useful. For example, agreeing that individuals will attend in person wherever possible, but in instances where not they will send over a written update for the patients ahead of the MDT. Other practices have considered dialling people in via conference call as an alternative.
THE IAM FORM: AN OVERVIEW Why not: trial it with a few patients to see how it goes? IAM stands for Information About Me, and the form has been developed as a patient held record. The form looks quite different to traditional clinical care plans and contains questions which are highly social as well as clinical. The form has worked very well to initiate a different type of conversation with older people, for example opening up difficult topics such as end of life wishes. The current form works best for patients living in their own home. A care home version is under development. Duarte, Inc. 2014 13
THE IAM FORM: MORE INFORMATION I.A.M has been accepted by NHSE as a basis for a care plan for the Avoidable Admissions DES and can be adapted to meet the needs of your patients and your surgery so go ahead and customize to make it your own! * I.A.M can be filled in by patients at home, with their families and carers, or with support from the clinical teams. It need not take long. I.A.M is a patient held document which can be changed, added to and enhanced as needs dictates for your patients. It can be used as a basis for discussions at an MDT for example. I.A.M facilitates an opportunity for our patients to think about their wider needs, their strengths and resilience, their own resources and priorities as well as their health and social care needs. I.A.M is underpinned by key set of principles to enable the patient to feel empowered and in control should their needs &/or circumstances change. I.A.M Fundamentally we want to improve the patient experience, reduce attendances and admissions to hospital (as appropriate) and ultimately realize efficiency savings with an ageing population through an integrated approach. I.A.M Is a word document which can be integrated into your clinical system so that key patient and GP details can be mail merged to save you time when preparing the forms. *Note: If you are already using the NHS England Care Plan template you are welcome to continue to use this, you do not have to use this form in order to be part of the 100 day challenge Email Carol Bladen (carolbladen@nhs.net) if you would like copies of either of the IAM forms.
COMMUNITY SUPPORT FOR PATIENTS As The 100 Day Challenge project developed, it became apparent that there are far more support services for patients than any one organisation was aware of. We learnt so much from each other. A simple Directory of Services has been produced containing details of the services available. This is available here: http://www.midessexccg.nhs.uk/your-nhs/guides-forparents/doc_download/1003-spor-directory-of-services..and includes information on a whole range of services available through: Provide Community Services Adult Social Care Reablement Services Well Being Centres Essex Cares Mental Health Team Pharmacies Community Hospitals/Community Beds Non-Emergency Patient Transport Services Acute Hospitals Hospices Out of Hours Walk in Centres Plus other reference Numbers
CENTRAL POINT OF ACCESS The existing Provide CPA for integrated care was established during the first 100 days as an access point for both older people and practitioners involved with the frailty cohort. This is now being developed to cope with increased pressure and to coordinate with a larger range of agencies e.g. incorporating clinical triage, social care expertise, representation from the voluntary sector etc.
FLAGGING AND DATA SHARING WITH MEHT (MID ESSEX HOSPITAL TRUST) The frailty challenge has seen new links established with MEHT through the set up of weekly data reports from MEHT to each team, detailing information around A&E admissions and unplanned admissions for the cohort of patients that teams are working with. This data also includes information on activity for the same cohort of patients 12 months earlier, allowing for a comparison on activity levels over time. MEHT are now also flagging these patients so that staff and consultants within A&E are aware that these patients are part of this cohort. A shared template is being developed which will provide A&E staff with more information about patients current care plans. Duarte, Inc. 2014 17
A selection of stories so far 03
SALLY The power of informal networks across the system The situation: Sally, the wife of an elderly patient calls the surgery. Her husband has recently been discharged from hospital and is unsteady on his feet and prone to falls. As such she s been pushing him around in an office chair since he s been back at home. However, their grand-daughter is getting married and so she wants to know of anywhere she could get a wheelchair for the next 3 days. What Changed? Previously this would have involved a lot of phone calls to the wheelchair service, begging from physio or the local hospital, and a lot of time and effort with no guarantee of getting him a wheelchair in time. Referrals to the wheelchair service are slow and cumbersome. Instead the GP emailed their contact at Age UK (who was part of the 100 day challenge team) who suggested the Red Cross may be able to help. This was passed to the gentleman's wife who duly contacted the Red Cross, and they loaned him a wheelchair for a week at no cost within an hour. The outcome: The husband had a wheelchair within an hour of calling, the wedding was beautiful and all enjoyed the day. The family donated 50 to the Red Cross as a thank you. What we learnt Building closer relationships across all parts of the system allows you to find efficiencies by using a connected network of practitioners. In this case an email and phone call solved a simple but difficult problem and made an old man (and a young bride) very happy.
BETTY Using the IAM to bring patients views to light, and initiate care plans The situation: Betty is an elderly lady with COPD IHD and end stage Cor Pulmonale with recurrent chest pain and heart failure. She is regularly in and out of hospital with breathlessness and chest pain and has had 22 attendances at A&E in less than 6 months. Most of these have resulted in a short admission, some increase in her medication and discharge home, only for her to be readmitted later in the same week. Betty s son has bipolar disorder and is anxious and often upset when his Mum is not well, he panics and calls 999 frequently. What happened? The GP went to visit and after some discussion the family and the patient decided to fill in an IAM form. This gave Betty an opportunity to talk about her wishes and opinions, and revealed she actually didn t want to keep going to A&E and instead wanted her son to have some support and wanted him to feel confident that she was OK. They all talked through a crib sheet of what to do when Betty became breathless or had chest pains. Betty and her son then filled in the form, and the GP then used this to form the basis of a care management plan involving Betty, her family, the care agencies, including the community COPD and heart failure teams. This gave her control over the situation, other agencies to call on and increased her son s confidence to support her. The outcome: To date she has had no further A&E admissions and her medication is better managed. What we learnt: Using IAM as a tool to initiate management plans and involve patient wishes is effective and can help people to share opinions which might not otherwise come to light.
DEREK Handling crises differently through stronger partnership working The Situation: Derek lives with his wife, who has advanced dementia. He looks after her alone with no input or support from anyone else. Recently, the situation has got a lot worse, with his wife s behaviour becoming uncontrollable. As a result, Derek breaks down. He calls the surgery in tears and speaks to his doctor, who can hear the wife in the background screaming abuse and confused exclamations to Derek. What happened? The GP knew this was a crisis and immediately contacted her social services contact through the frailty work. He arranged for Derek s wife to be seen immediately and within an hour she had been assessed and moved to a safe place for respite care. (no acute medical problem had already been excluded). Previously social care support took weeks to arrange and in this crisis it was likely that she would have been sent to MEHT as an acutely confused lady, been admitted and maybe discharged to a care home, splitting up a devoted couple who only had each other. The outcome: Derek and his wife are now back together at home and coping well, with social care support, a network of carers and help and a list of phone numbers to call if he needs them at any time. Help can be gained quickly when needed such as if his wife needs to go into respite care again. What we learnt: Crises do occur but need not result in admission or long term disaster.
IVY The IAM as a tool which can relieve pressures on carers The situation: Ivy is a fiercely independent lady in her 90s who lives alone. She has isolated periods of ill health (she suspects bouts of IBS) where she is in a great deal of pain, sometimes faints, and has toileting accidents which upset her a great deal. She is struggling to cope, particularly as her sight is failing, with complete loss of vision in one eye and partially sighted in the other. She relies heavily on a close neighbour (who is elderly herself) and a friend who resides in Springfield. However, the neighbour is elderly herself and wishes to find an alternative source of qualified help for her good friend. However, she recognises this is a very difficult and sensitive subject to broach with Ivy. She mentions it to Ivy s daughter, who calls the GP. What happened? The GP calls the community agent, who discuss and decide to use the IAM form as a way to broach the topic of her care. An appointment time was arranged where Ivy, her neighbour and daughter could all be present. Discussing the form together helped to raise the issue of pressure on the neighbour in a sensitive way, and Ivy recognised that she must think about other ways of accessing support. The outcome: Ivy now has an IAM form at home, with a number for the Single Point of Access that she can call if she should have another bout of ill health. She knows that this number can link her to organisations able to provide low level assistance. The Neighbour and daughter also have the telephone number and are confident that this will make a difference. What we learnt: The importance of involving both formal/informal carers in conversations around care planning.
Next Steps + Future Developments + Sign up! 04
WHAT S ON THE HORIZON? Embracing this way of working with the unplanned admission cohort. Increasing the number of older people benefitting from a different type of care, with your help! Utillisation of the Risk Stratification tool to help identify frail/at risk patients Volunteers: Exploring how practices can engage more closely with volunteers to support older people. Closer work with MEHT: Producing a joint frailty template for information sharing : to capture key data for frailty, unplanned admissions, palliative care and ability to erefer in SystmOne. Engagement with Ambulance, 111 and Out of Hours services is underway to develop a shareable frailty template across the whole system. The Central Point of Access The CPA is now being developed to cope with increased pressure, to coordinate with a larger range of agencies, and to be operating over extended opening hours Explore how best non-systmone practices could benefit Engagement with care homes to explore how new ways of working can be adapted. Most importantly help us identify more by joining the challenge
WANT TO HEAR MORE / SIGN UP Get in touch with one of the current Challengers Dr Liz Towers: Whitley House Surgery. Mobile: 07712 898065; elizabethtowers@nhs.net Dr Carol Bladen: St Lawrence Medical Practice & Silver End Surgery: 01376 552474 carolbladen@gmail.com Amy Brass: Practice Manager: Whitley House Surgery: 01245 347539 amybrass@nhs.net Gareth Howells: Head of Unplanned Care, Mid Essex CCG: 01245 397656 gareth.howells1@nhs.net