Well in a nutshell its all about offering older people better, joined up health, care and rehabilitation services - now that has to be a good thing, and certainly something that we can all follow and potentially participate in.
There are 6 Vanguard sites currently working to turn services for older people into joined up integrated services which truly reflect the needs of older people.
Lets have a look at what each Vanguard site is working on.
The Wakefield Care Home Project is designed to break the mould for older people in care homes, tackling social isolation and shifting from fragmented to connected care. They are developing a comprehensive approach to proactive assessment and care planning based around the wider determinants of health ‘somewhere to live; somewhere to love; something to do’ to optimise residents’ health and life experience. Sounds great but what does that mean in reality? Well an elderly patient in extra care housing could be supported to resume their hobby of walking following a hip replacement, helping to improve both physical health and quality of life. How are they going to do this? Move to a one GP one care home model, have a dedicated multi-disciplinary team for care homes, provide access for all care homes to their resident’s records via the implementation of SystmOne in care homes, develop a comprehensive training and education programme for care homes staff and have weekly e-consultation sessions for care homes with secondary care geriatricians.
The Gateshead Care Home Project is a joint approach by NHS Newcastle Gateshead CCG and Gateshead Council. A new organisation is being created called the Provider Alliance Network (PAN) which will deliver the Gateshead Integrated Community Bed and home-based care service. PAN will provide holistic care and seamless support across the traditional health and social care boundaries. So how are they going to do this? Individual GP practices will be allocated to a specific care home, making it possible to offer greater continuity of care and more effective prevention of illness through regular home visits. They are reviewing the care pathway and a new model for contracts and payments as well as the development of cocommissioning for all community bed and home based care. Cocommissioning will bring a simplified and joint approach to enhanced healthcare, making it easier for patients and professionals to navigate, with the potential to take out some transactional costs. Can it work? Well this personalised care delivery and multidisciplinary working has already brought a 14% reduction in avoidable hospital admissions, together with an improvement in the quality of care delivered.
East and North Hertfordshire Clinical Commissioning Group will focus on enhancing the skills and confidence of care home staff through a package of education and training. The programme will create dedicated multi-disciplinary teams for Care Homes which will include GPs, community psychiatric nurses, district nurses and geriatricians. How will they do this? They will work with homes to support residents proactively as well as if a resident’s condition deteriorates. They are developing a rapid response service so that care homes have access to services in two localities with a combination of community nurses, matrons, therapists and home carers who can be deployed within 90 minutes if required. This means care home patients will be supported in the home by staff that are accredited because they have undertaken a package of education and training. In addition patients will know that should their condition deteriorate, a team of experts is ready to respond to their needs before making an assessment as to whether they need to go to hospital.
Nottingham City Clinical Commissioning Group will provide a structured and pro-active approach to care, complemented by a number of local innovations including; mobile working for Primary care; access to SystemOne for care homes; remote video consultation between care home residents and GP; remote access to resident health data through telehealth; and increased use of telecare. these measures will ensure that all potentially long hospital stays are proactively managed and builds on work already initiated with acute trusts, care homes and community services to develop a ‘pull’ approach to acute discharges, ensuring that social services are involved at the earliest opportunity. Effective mechanisms to capture the experience of patients discharged into a care home setting will ensure a responsive ‘learning lessons’ feedback loop, so services can be continually adapted and improved.
Sutton Homes of Care Vanguard will develop a care home provider network to support training across local care homes, and a new model of health and social care locally, which will include tele-health and expanded in-reach services, providing the right care at the right time where patients need it. This means a patient who has three in-patient hospital stays in a month, will now get the care they need from hospital specialists at home, enabling them to stay close to their family and friends. How are they doing this? They have introduced a number of interventions including the development of a community team to help prevent unnecessary admissions to hospital and the establishment of end of life care nursing teams. They have also set up a joint intelligence group and established forums for care home managers and senior nursing staff to share best practice, education and training. Will it work? Well these interventions have already demonstrated not only an increase in the quality of care provided to residents, but have also shown a reduction in pressures on the health system.
The Airedale Partner’s Vanguard objective is to enhance the quality of life, and end of life experience of thousands of nursing and care home residents living in Bradford, Airedale, Wharfedale, Craven and East Lancashire. By using enabling technologies, such as telemedicine, the Gold Line and Intermediate Care Hub, nursing and care home residents and their carers are already benefitting from being able to access expert advice and support remotely 24/7. You can read about their work here on FabNHSStuff http://fabnhsstuff.net/2015/02/20/round-the-clock-healthcare-thanks-to-digital-innovations-at-airedale/ Through the Vanguard programme, partners intend to go further and develop a more proactive health and social care enabling model focusing on optimising residents individual capabilities and building new clinical models of care. How will they do this? Using technology is the key and there will be an extended use of telemedicine providing a single point of access to all aspects of specialist health and care advice. What will this mean for patients? Well an example is that a patient with Parkinson’s disease living in a residential home will be able to access clinical advice and support through secure video conferencing at any time of the day or night, so in the event of a fall, an experienced nurse in the tele-health hub would be able to assess the patient using the video link and after consultation with an A&E consultant will be able to arrange for them to be cared for in their familiar surroundings, rather than transferring them to A&E. This enhanced care model provides links to social care to complete a falls prevention assessment of the layout of the patient’s room, and a multidisciplinary team including carers, nurses, therapists, social care and the voluntary sector work in partnership to deliver care and support, promoting independence and improving quality of life.
So we can see that already the Vanguard learning; the 'how to' and the 'what does it mean for patients', is producing transferable service ideas that we can all learn from and use. So get to know your local Vanguard site and lets see how you, the social movement of fabulous sharers and collaborators, can be instrumental in applying this service ideas within your own area of work.