What does being a vanguard mean to you?
Being a Vanguard site has been an incredible opportunity for Nottingham City. It’s given us support to innovate and allowed us to improve our offer to care homes residents. Crucially for us it has been an opportunity to co-design, with the rest of the Care Homes 6, the framework for a new model of care – essentially a blueprint for ‘what good looks like’ in care homes at this point in time.
What problem did you want to solve? We knew we had many of the right elements in place already – for example, we already have a well-established GP Local Enhanced Service, advocacy and support services and excellent nursing and dementia services dedicated to care homes but we wanted to focus on areas of work that we felt could make the greatest difference and have the biggest impact on: • Improving health outcomes for residents • Increasing resident autonomy and choice • Improving the quality of services available in care homes • Reducing the number of conveyances to hospital from care homes • Reducing non –elective activity and spend in the acute sector on care home residents
In addition, we know that this is a difficult time for the care home sector so we also wanted to be able to support them at this critical time.
How did you go about it? We started with our residents – finding out what mattered to them the most. We commissioned a specific piece of engagement from Age UK to interview staff, families and future users of care homes. As Age UK already deliver a ‘Residents Representative’ service in our care homes, they had the relationships we needed to draw on to make this a success. We benchmarked the results from our work against national data with the help of ‘Experience Led Care’ and this led to the development of our ‘I statements’, which keep our Vanguard patient-focused.
We also wanted to improve and refine our existing offer to care homes (see above in question 2) so we have introduced and funded some new initiatives including: • Part funding a very successful Transfer To Assess pilot to help address the issues care homes residents faced at the end of their stay in hospital. • A Care Coordinator role specifically for care homes residents to help with complex care.
• The ‘Worry Catcher’ – a volunteer service which gathers the soft intelligence we need to understand our performance at the patient level. • Extending the City’s community-led Self-Care programme into care homes to support personalisation and increase autonomy and choice. • Introducing work to improve internet connectivity and system interoperability in care homes and extending our very successful Integrated Assistive Technology programme into homes to help manage clinical risk, reduce acute activity and improve proactive care. • Introducing a programme of clinical polypharmacy review into those care homes with the highest rates of admissions to and discharges from hospital.
In practical terms what difference have you noticed and has the way you work on a day-to-day basis changed at all? We’re seeing quality improvements in the care homes; we have a dedicated quality tool and the scores that care homes receive annually are improving. More homes are hitting our performance thresholds on our first quality visit and most are now rated either ‘satisfactory’ or ‘good’ at CQC inspection visits. We are also using data better to address issues as they arise and thinking about services in a more integrated way – as we test the elements we also find structural implications about the way services are commissioned. The focus on replicability and spread has meant we are working alongside our neighbouring CCGs and out into the STP footprint, looking for economies of scale and finding ways to align service pathways and tools.
What has the reaction and what has the level of staff engagement been like? We are very fortunate in Nottingham City to have a good level of engagement from care home providers, particularly through the Care Homes Managers’ and Activity Coordinators’ Forums, which are supported by Nottinghamshire Healthcare Trust’s Dementia Outreach Team. We also have good provider representation on our Care Homes Steering Group, meaning that care home providers are involved in the design and performance management of the Vanguard.
The response to our offer has been very enthusiastic, and providers have been really helpful, especially with finding quick wins as we roll out elements of the programme. For example, the city’s Activity Coordinators have helped us design a model for social prescribing in care homes, so that activities are personalised and focused on helping residents to self-care as far as possible. In response we’ve offered them Self-Care Champion training and resources to help them leverage more support from the wider community.
How would you explain the way your new care model works to members of the local community? ➢ We want to make sure that people in care homes have a positive experience of care, that they’re seen as an individual and their capabilities are recognised, as well as their difficulties.
➢ We want to keep people as well as they can be, as active as they can be, and we want their care to reflect their interests and relationships outside the care home.
➢ We want to offer them a relationship with a specific GP who will oversee their care with regular home rounds and a proactive approach.
➢ We want to use technology to check on their health and wellbeing, to manage clinical risk, to share information across the ‘virtual MDT’, and to offer wraparound care 24/7, whether or not there is a nurse on the premises.
➢ We want to make sure that they’re taking only the medicines that they need, and that they are involved in decisions about their care and their medication.
➢ When they are ill, we want to treat them at their home whenever possible, and if they do need hospital care, we want to make sure that that they’re back home as soon as they’re able to come, with the care home kept up to speed with what is happening to them in the meantime.
➢ If they need extra help to recover before coming home, we want to make sure they get that help outside of hospital, with support to regain mobility where possible.
➢ And at the end of their life, we want to make sure people are receiving the care they want, in the setting that they want, with advance care planning and the right support.
What is already having or what is going to have the greatest impact and value for patients as a result? Use of technology in care homes is a big step forward. When we applied to be a Vanguard, care homes weren’t linked in – they had no access to medical records, for example - and they weren’t using the technology they did have very effectively. Our integrated assistive technology programme comprises a ‘virtual MDT’ with real-time access to good quality clinical data, shared records, on-site testing, increased clinical oversight and wraparound care for residents. This will mean that (for example) patients in residential homes can draw on nursing support, remotely via video software, 24/7; and that those nurses will have access to good quality clinical data which they can use to inform decisions about the appropriate care for that patient.
Do you have any great case studies that immediately spring to mind or can you tell me what your most satisfying day at work has been since becoming a vanguard? Although these were on two different days, they relate to the same thing, which is being able to hear and show others how the work we are doing is making a difference to some of the most vulnerable people who live in our care homes. The day that our Governing Body heard a patient story, illustrating the impact of the Dementia Outreach Team (http://www.nottinghamcity.nhs.uk/images/stories/docs/GoverningBody/2016-17/June2016/203a_16_Patient_Story.pdf) and the day that the Care Homes Nursing Team gave a presentation about how they were able to support a person to live independently was both inspirational and quite humbling.
What do you think has been the most difficult challenge or barrier to overcome? The workforce issues are difficult to address – they extend far beyond the care home setting but are especially pressing there. Our providers tell us that Nottingham City has particular difficulties with staff turnover (both professional and non-professional), reliance on agency nurses, and leadership continuity. However, we are also finding that posts that are linked to the Vanguard or which describe Vanguard innovation are seeing a higher than usual level of interest. And we are part of a regional Nursing Supply and Demand Group so care homes are (for example) part of bids for Nursing Associate pilots. We are also linking up work around home care and care homes so that standards and training for non-professional staff can be aligned as far as possible.
Vanguards are leading on developing new care models that will act as blueprints for the future of the health and care system in England. What advice would you give to anyone looking to adopt your new care model? Reassess and simplify your contracting arrangements. The care home sector is already complex enough; we should not add layers of contractual complication which can detract from quality of care.
Fundamental to our care model has been the shared contract for care homes which we have with the local authority. It has meant a reduction in compliance work for the care homes, a reduction in duplication for us, and we now share contractual and oversight mechanisms. We use the NHS contract, which from our perspective as a CCG is ideal. We have also developed our own quality assurance tool, called iCare. The arrangement has proven so successful that the surrounding CCGs have also taken up this model. We are now thinking about how we can better commission in-reach services for care homes, with the aim of simplifying these arrangements too.
How are you sharing learning? The Care Homes Vanguard sites work closely together to test, evaluate and share with one another. That learning is captured in the Framework for Enhanced Health in Care Homes, which the New Care Models team at NHS England published on 29 September 2016. Locally, we are sharing our learning through our STP plans – we have 5 Vanguards in the Nottinghamshire STP footprint – and we are sharing tools and resources with a large number of interested parties nationally. We are very open to sharing – please do get in touch.
What do you think your vanguard and the service it delivers will look like in 12 months’ time? In 12 months’ time I think the care homes Vanguard will be focused on mainstreaming the most successful of its workstreams and delivering services in line with the care home framework published on 29 September 2016.
From your work so far, what's your one top tip (or learning) that you could share right now with us that we could learn from and implement within our work areas? The care home sector is very varied, so one size fits all approaches are even less appropriate than usual. Work closely with your care home providers, with staff at all levels. Develop engagement mechanisms that work for them; be prepared to go to them rather than expecting them to come to you; listen, learn and respond.