The Kings Fund andPioneer Communities

Kernow CCG Governing Body

June 2013

Joy Youart

Case for change

Increasing demand from older people

Unsustainable in current system

Patients not seen in most appropriate place

Avoidable delays

Continuing healthcare over-subscribed

Leadership summit has prioritised

• Kernow one of 10 national learning sets• Learning and sharing ideas, best practice• Clinical leadership• Influencing national policy• Large scale, fast-paced change

Self care

Support older people

at home

Enhanced support at

homeManage Crisis

EffectivelyInput in

acute setting

Frail Elderly Pathway – Care standards (time based)

Enhanced support at

home

Support Older People

at Home

Std C1. For all patients identified as being at risk of admission to an acute hospital, an assessment *will be initiated within 2 hrs of the requestStd C2. All patients in crisis will start to receive a package of enhanced support at home within 2 hrs of the need being identified. NB working patterns

Manage step down from

acute effectively

Std C3. Within XX hrs of the need being identified for a Community bed, all patients in crisis will be transferred to that bed

Std T1. All patients will be transferred to the most appropriate care setting following a decision of ‘medically fit for discharge’ as follows:

* All assessments are carried out using a Comprehensive Geriatric

Assessment (CGA) approach

Std A1. On arrival in ED / admissions unit, all elderly patients at risk of adverse outcomes will be ISAR scored within 4 hrs .

All standards relate to patients assessed as being ‘frail’

Std A3. All patients in hospital will be assessed* before they leave hospital. HOLD pending D2A discussions

Crisis Acute Trf of careStd H1. All patients remotely identified as an emerging risk (by e.g. the Devon tool) will be assessed* within 7 days

Standards to be developed

Home/care home

Self care

Home/care home

Std H2. Primary care will respond to a request for a GP visit and make a ‘treat/refer/admit /no action’ decision within 4 hrs

Std A2. Patients with an ISAR score of 3 or more will be notified to the CGA case manager and assessed*within XX hrs

T1a. For first time care home placement: Arrival by 17.00 within XX days of the decision

T1b. For return to care home: Arrival by 21.00 if decision by 14.00. By 12.00 next day if decision after 14.00

T1c. For assessment bed / I.C. bed: Arrival within 24 hrs between 10.00 and 16.00

Pioneer Communities

Expression of interest: Health and Social Care Integration Pioneers

Builds on learning: brings in expertise• Data analysis• Modelling• Health economics• Contract design• Workforce advice• National political support

Norman Lamb MPHealth minister

What’s on offer?

• Consideration of freedoms and flexibilities at national level

• Support to address local barriers

• Commitment to look at changes to national rules

• Expertise, but no funding

Even if we don’t get chosen, the process of documenting our potential, commitment and aims for integrating care and support

will help to galvanise the economy into a single, shared and collectively delivered vision.

Delivery

Immediate local change

Agreed model

Full delivery

October 2013

Max two years

Fiveyears

Freedom to test cash-

releasing ideas

One extra patient, per practice, per week, cared for in an appropriate setting =

money released for lower cost, community based alternatives