SIGNS & the Frail Older People programme Update to Rushcliffe - - PowerPoint PPT Presentation

September 2013 Jeremy Griffiths – Chair of SIGNS, Clinical lead

SIGNS & the Frail Older People programme

Update to Rushcliffe CCG Governing Body

RCCG/GB/13/125

Activity and financial implications

(Nottinghamshire)

Commissioners Nottingham City CCG Rushcliffe CCG Nottingham NE CCG Nottingham West CCG Providers Nottingham University Hospitals Nottinghamshire Healthcare Nottingham CityCare Partnership County Health Partnerships Councils & 3rd Sector Nottinghamshire County Council Nottingham City Council Carers Federation

SIGNS- Frail elderly programme (Strategy & Implementation Group for Notts South) ; a collaboration of commissioners, providers and 3rd sector organisations

• Use time based standards to measure how well the system is performing for

the citizen and where priorities need to change

• Commit to Comprehensive (Geriatric) Assessment for frail older people

(CGA) as the way we all assess frail older people.

• CGA 5 domains (physical health, mental health, social and economic status,

functional status, environment) a care plan that is communicated to all those who will provide care a case manager to ensure that this all happens.

• Enable community services to provide services for citizens in a timely way.

Services are proactive, flexible and care that is always appropriate to need.

• Integrated with other providers
• Reduce numbers moving to care: Citizens moving to residential care

receive CGA:plan is enacted before any move.

• Treat the avoidable admission or delay in transfer of care of a citizen as

an untoward event

• Implement a process to truly understand and aim to limit stays of more

than 50 days in our hospital and community beds (and a rolling reduction thereafter)

• Use differences between the needs identified from Comprehensive (Geriatric)

Assessment and current provision to invest in appropriate services.

SIGNS - Strategic objectives

• Choose to Admit
• Transfer to Assess
• Support to Thrive
• SCOPES (Systematic care for older people in

elective surgery) All underpinned by:

• Comprehensive geriatric assessment (CGA)
• Time based pathway standards

Strategic priorities for change

Integration Intermediate care

Choose to Admit

Comprehensive Assessment at the front door of the hospital

• The hospital provides CGA for frail older people as close to the

front door as possible (a geographic area(s) rather than a peripatetic service).

• A case manager ensures that the Plan from the CGA is

communicated.

• Where admission is not necessary, staff from hospital,

community, primary care, social care, mental health, third and private sectors work together at the front door to provide evidence based alternatives to admission

Transfer to Assess

Case Managers ensure timely transfer of care from hospital

• The intensity of the care provided will be appropriate for every

citizen in a hospital or community bed.

• The Case Manager, hospital, community, primary care, social

care, mental health, third and private sectors work together to provide rapid and evidence-based alternatives to on-going admission

• The citizen transfers from hospital within timescales agreed in
• ur Standards of Care.

Support to Thrive

Case Managers ensure timely provision of community based services

• Services are seamless from the citizen’s perspective.
• Single points of access to health and social care are used by

default.

• All intermediate care and reablement (recovery and

rehabilitation) services are aligned around current citizen’s needs.

• Pathways are sufficiently flexible to eliminate the use of the

hospital as the carer of last resort.

6 Strategic Priorities aligned to ‘levels of care’ Choose to Admit Transfer to Assess Support to Thrive SCOPES

(planned care only)

Comprehensive Geriatric Assessment (CGA) Pathway Standards - time based

Enabling sub groups - Outcomes & Commissioning, Communications & Consultation, Workforce Planning

Support to Thrive

Enabling approach - SHARING of information, risks, challenges, successes etc. will be key

Choose to Admit and Transfer to Assess projects

1.Care co-ordination team (underpinned by NUH’s – flow, streaming, discharge project) 2.Community Access 2.Community Access 3.Community capacity 3.Community capacity

• 4. CGA / case

management

• 4. CGA / case

management

• 4. CGA / case

management Patient Information exchange including Alerts

Care Co-

• rdination

Team Community Hubs Community capacity

Choose to Admit/Transfer to Assess - Planned deliverables

CGA and information sharing

By 1st Oct 2013 By March 2014 By 1st Dec 2013

Next 3 months (as at 5th Sept)

Establish single integrated Care Co-

• rdination Team to support Choose to

Admit and Transfer to Assess, reconfiguring existing resources, to case manage all ‘supported transfers’ Current resources working as

• ne team to support ED, ass

beds and 8 HCOP wards (14th October) Community hubs manage all health and social care local service capacity and organise packages of care to support transfer from hospital within 24 hours CCG-based community hubs established with access to a clinician with streamlined interface to Care Co-Ordination Team Community capacity (bed and home based) increased to meet the needs of patients on HCOP and medical wards. New commissioner model for community places agreed for County and City Agree and implement a method of recording and sharing CGA across primary care, social care, NUH and community services Standardised transfer of care template used to share information on needs between NUH and community hub (fax) tbc Community hubs able to commission reablement services 21 beds that are staffed to meet the needs of the most complex patients as part of an integrated community service Transfer of care template

• perating electronically on

SystmOne

Next 3 months – other priorities

SCOPES

(planned care only)

Strategy will be developed - for CGA approach to be implemented across Greater Nottingham

Communication

Comms plan developed and approved by SIGNS on Sep10th. Implementation of first 3 months of activity CGA SIGNS approved proposal re: Oncology will go to readmissions panel and if successful, recruitments / implementation will start Support to Thrive Initial scoping work and development of strategic direction