Older People and Integrated Care Update PEG 24 th January 2019 - - PowerPoint PPT Presentation

Older People and Integrated Care Update PEG – 24th January 2019

Annette Bunka – Head of Older People and Integrated Care, Merton Simon Galea – Project Manager, Older People and Integrated Care, Merton

Overall Objectives

• Keeping people well at home
• Delivering care at home or closer to home where possible
• Reducing the demands for emergency services, including London

Ambulance Service (LAS) calls and the need for transport to hospital.

• Avoiding Emergency Department attendances and avoiding/

shortening emergency admissions and optimising discharge processes

• Improving integration across services and the user/carer

experience

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Priorities

Integrated locality teams, including support for those identified with frailty and end of life care Supporting discharges from hospital Enhance and broaden the scope of intermediate care provision Enhanced support to care homes Supporting older people with multiple long term conditions

• Multi –disciplinary working across health and social care
• Each GP practice in Merton has committed to working in 1 of 4 groupings

(clusters), with a scheme incentivising GP practices to provide additional support for complex patients.

• Community services have aligned their nursing teams to the 4 clusters.
• Each practice has a Health Liaison Social Worker from London Borough of

Merton.

• 5 Co-ordinators have been recruited to support the most complex patients, those

with severe frailty and those who are in the last year of life.

• SW London and St George’s Mental Health Trust have identified a liaison point of

contact for all practices.

• St Raphael’s Hospice attend practice multi-disciplinary team meetings.
• Improvements in care planning, including 733 patient held

admission prevention plans and 320 Coordinate My Care records.

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Integrated Locality Teams & Frailty

• Proactive identification and review
• f those who are living with frailty:
• Locally adapted Healthy Ageing

Guide distributed to GP practices, community services, libraries, social care and voluntary sector.

• Where required, referral to

appropriate services e.g. falls prevention classes, case management/ care navigators.

• Healthy Ageing Guide being

updated- comments welcome

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Frailty

• Integrated Intermediate Care Single Point of Access started in

December 2018 – This is a single point for triage and case allocation for those who may require interim support/ rehabilitation.

• Initially this has been set up for referrals from acute trusts to

support smoother discharges.

• This will be expanded to support admission prevention in 2019/20
• Daily review of patients at St George’s and a weekly escalation

meeting has reduced delayed transfers and supported earlier discussions about complex discharges and improvements in information to support patient transfers.

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Supporting Discharges

• A new bedded provision, which will be run by community services

is due to open late February 2019, which over time will enable increased scope for more prevention of admission.

• Older people’s liaison service at St George’s now also works within

the Emergency Department and health and social care are working more closely to help people out of hospital sooner.

• Working on a case for GP Input into the Rapid Response service

(MERIT) which aims to provide a rapid response to support people in their own homes and more GP input into the community beds.

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Enhance and broaden the scope

• f intermediate care provision

• Red bag pathway launched in

21 nursing/ residential homes

• n 29th January 2018.
• Red bags contain important

information about the resident’s health.

• Care homes have reported

usage of the red bag on 70

• ccasions from Feb-Nov 18.

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Enhanced Support to Care Homes

• Merton Joint Intelligence Group continues to meet monthly to

improve quality and Merton Care Home Forums taking place regularly.

• A programme of care home training in relation to identified priority

areas is being delivered (complementing support/ training that is already provided).

• Funding agreed from Health Education England to support

training including falls prevention

• Through the range of initiatives there has been a reduction in

emergency transport from care homes, instead using support from community services.

• A proposal is being drawn up to provide more input and support

to care homes across Merton and Wandsworth.

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Enhanced Support to Care Homes

Older People with Multiple Long Term Conditions

• Giving patients the option of a referral for an holistic geriatric

assessment (HARI) instead of attending multiple outpatient appointments.

• Making greater use of the HARI service at Nelson
• Look holistically at the person, their level of frailty and the risks and

interactions of using multiple drugs to treat one or more conditions.

• Undertake patient engagement to develop appropriate communications

to encourage patients to ask for the change – views welcome

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Thanks for listening. Any questions?