South TeesIntegration & BCF Programme2017/19
Integration Theme / Service/Scheme & Description / Coverage / Plan 2017/19 / ADMISSION AVOIDANCE / DISCHARGE HOME / KEEPING PEOPLE HEALTHY / OUT OF HOSPITAL CARERecovery & Reablement:
Step Up & Down
Recovery & Reablement:
Step Up & Down / Community Recovery & Independence Team.
Provision ofreablement and rapid response services in the community including OT and physio. / R&C / Further expansion through core and iBCF to meet increasing demand, incorporate earlier supported discharge and deliver healthcare interventions.
Recruitment commencing April 2017 / / / /
Supported living settings for Recovery and Reablement.
4 properties, - 2 flats including 1 in extra care housing, a fully adapted house and a bungalow
For step up/down where someone can’t return to their own home initially. Enabling further assessment, reablement and recovery time, along with confidence building to return home. / R&C / Pilots to be evaluated from July 2017 assessing activity and outcomes.
Potential further pilot of same or additional accommodation for End of Life care to facilitate discharge or prevent admission where home environment not suitable for care requirements. / /
Residential reablement, recovery and assessment beds.
Commissioned beds in residential and nursing care settings. Providing a range of recovery, rehabilitation and reablement support including OT and physio. Also providing “time to think” and more appropriate environments for completion of assessments and application of CHC processes / R&C / Existing arrangements extended for up to 2 years.
Enhancements proposed for 17/18 include medical cover and dedicated Social Work capacity. Also aim to reinstate delirium beds.
Options for longer term provision are being explored and could include a South Tees approach or R&C only. Current direction of travel is for an “in-house” facility providing the full model of residential intermediate care. / / /
Intermediate Care Medical Model
Provision of a wraparound medical support model for patients in intermediate care beds / R&C / Options being assessed to identify the best model to deliver this. / /
Commissioned Reablement – various schemes to include community equipment, agency caseworker, and telecare / M / Continuation, business as usual / / / /
Residential Rehabilitation:
Bridges the gap between primary/community care and hospital service. Provides intense rehabilitation in 24/7 setting to maximise individual's potential for independent living / M / Continuation, business as usual / /
Overnight Planned Care
Provide overnight calls to help with changing pads or turning. This enables the person to stay at home even if they need care that domiciliary care providers cannot provide / M / Continuation / /
Time to Think Beds:
Provide the opportunity of a longer period of recovery and reablement on discharge from hospital to maximise the individual's potential and opportunity to return to their home / M / Continuation / /
Carers Support / Core Carer Support:
Identification, assessment, information, advice and support. / South Tees / Fully commissioned. Business as usual / /
Young carers support:
Assessment and activities through a holistic approach. / South Tees / Fully commissioned. Business as usual / / /
Information and support in hospitals.
Dedicated support into hospital settings to identify new carers and support discharge processes in order to ensure early carer support and reduce risk of readmission / South Tees / Fully commissioned. Business as usual. / / /
Short breaks for carers:
A fund administered in Partnership with Carers Together to enable a range of one off breaks for Carers. This supplements the more regular support and respite services provided through commissioned support and direct payments mechanisms. / South Tees / Further development work over the next year to allocate funding to a range of short breaks and respite. / /
Promoting Prevention and Independence
Promoting Prevention and Independence
Promoting Prevention and Independence / Community Agents
Deliver a range of low level, short term interventions tosupport an individual’s ability to remain at home for as long as possible / R&C / Fully commissioned. Business as usual / / /
Social Prescribing Practice Link workers:
Working with individuals and linked to wider virtual team of community Agents and Transformation challenge. Short term case management and provision of and referral to range of non-medical support. / R&C / Pilot operational from October in 3 Practices in Redcar. Roll out to Eston practices has commenced. Evaluation will inform extend and speed of roll out but plan is to implement East Cleveland pilot within 6 months and roll out to all Practices across Redcar & Cleveland over the next 18 months. / /
Community hub –RPCH
VCS and link worker working from RPCH. Improving access for self- referral and through Practices to non-medical help and support / R&C / Operational from April. Options for further settings to be explored informed by evaluation of activity and outcomes. /
Befriending:
Provision through Age UK and Helping Hands / R&C / Part of the wider social prescribing model. Funding VCS services to provide additional capacity will be an ongoing requirement. Subject to ongoing evaluation and commissioning. / /
Mental Health support: Redcar Mind
Early intervention and range of mental health support and advice. / R&C / Full service and themed review being undertaken using “Better” methodology. Provision being redesigned to harness and support community capacity. /
MIND Reablement Service
Provides emotional and wellbeing support to individuals with long term conditions to help them manage their conditions and reduce the risk of their admission or readmission to hospital / M / Continuation / / /
Community Connect: Support so more people can remain in their own home for longer and are supported and connected in their community. / M / Continuation
Community Connect started in February 2017 / / /
Stroke Club
To support stroke survivors to regain and maintain their independence
• To promote self-awareness and self-management of their condition
• To deliver tailored and specific physical activity sessions for stroke survivors
• To improve overall health and well-being of stroke survivors / M / Continuation / /
Care at Home Medication Assistance:
To prevent unnecessary admissions , support timely discharges, reduce unnecessary admission to residential and nursing care and focus onrehabilitation and improved outcomes / M / Continuation / /
Assistive Technology Team:A dedicated team working alongside social workers embedding the principal of assistive technology and be able to access a wide range of telecare and assistive technology equipment, tailored to the individuals needs to support them to stay independent / M / Continuation / / /
Eye Clinic Liaison Officer:
Expansion of hospital based Early Reach service to enable a greater number of blind and partially sighted people access to preventative support at the point of sight loss diagnosis, deterioration or crisis / M / Continuation / / /
My Life Programme
Provides support to people with long term neurological conditions or chronic pain to help them manage their condition and avoid admissions / South Tees / New provider for 2017. To be further enhanced and evaluated in 2017/18 with full embedding of model in 2018/19. / / /
Operational Integration
Operational Integration / Integration of Continuing Health Care CHC Design and Implementation Group formed to develop an integrated care management model to deliver better outcomes for patients and efficiencies. / South Tees / Proposed model approved for progression and detailed work up. Full integrated service design to be completed in 2017.
Pooled budget arrangement to facilitate without prejudice cases to be in place in April. / /
Care Networks - Alignment of Primary, Community and Social Care.
Creating virtual/wrap around teams for individuals within defined populations with integrated pathways for assessment and delivery along with robust information sharing. This includes community health services, social prescribing link workers, therapies and social care and VCS. Initial work commenced in RC but will inform wider South Tees approach
. / South Tees / Development work in 2017 to include defining population clusters and needs assessments.
We will undertake small scale testing within one or small number of practices forming natural populations.
Implementation plan to be designed and agreed by March 2018 for roll out. / / /
Rapid Response Integration
Combine existing rapid response health and social care pathways and services to enable a more patient centred approach to those people requiring crisis intervention at home. / South Tees / Continuation of integrated pathways and alignment of working practices. / / /
Integrated Enhanced Falls Service Preventative and reactive multi-agency service to support falls patients and those at risk of falls. / South Tees / To design and implement a whole system approach to falls risk assessment and management. Building on the work done in Care Homes this will embed consistent training, assessment tools, management protocols and reactive interventions across all settings and agencies. / /
Single Point of Access
A streamlined process for access, assessment and care, by bringing together the South Tees care and health access services.
Phase 1 “lift and shift” of existing access points to a single location is now operational. Phase 2 (full integration) to be commenced in 2017/18. / South Tees / Evaluate implementation of phase 1 and progress areas for improvement/adjustment. Using the analysis conducted in phase 1 identify further service areas for inclusion in the SPA
Develop full integrated way of working across 7 days and appraise delivery options – eg hosting, new jointly accountable organisation.
Identify IT integration requirements and write specification for IT integration solution / / /
VCS Liaison Support for the VCS to continue their role within Middlesbrough to identify and support intelligent commissioning / M / Continuation / /
Proactive Health Care to Avoid Admissions / Incentive scheme for GP Practices.
To shift activity from unplanned urgent care at A&E into primary and community care through a range of Practice based schemes. / South Tees / Evaluation of the range of schemes introduced to determine effectiveness and inform PBR model going forward. / /
Urgent Care and Admission Avoidance / Support to A+E/AAU to avoid admissions Support for:
-7 day staffing including a medical decision maker
-3 additional A+E consultants
-Therapies Team in AAU and Front of House / South Tees / Continuation, business as usual. /
Effective Discharge / Trusted Assessors:
Identify and appoint Trusted Assessors to facilitate discharges building on initial work trialled by the acute trust / South Tees / To be progressed – evaluation of the number and types of assessments that might be suitable for a trusted assessment service, the impact this could have on reducing length of stay and delayed transfers of care (DTOCs) and if quality improvements are experienced by patients and families. / /
DToC Liaison Officer:
Dedicated post based in the acute trust and attached to the Hospital Social Work Team to liaise with relevant stakeholders to reduce delayed transfers of care / South Tees / Continuation and evaluation of impact on post at end of 12 months / /
CHC/Discharge to Assess Interface:
Allocated funding to ensure more CHC assessments take place outside of the acute hospital and introduce weekly reviews of patients in recuperative placements following hospital discharge / South Tees / Scheme to be evaluated after 12 months to monitor ongoing compliance with national target, impact on reducing length of stay and delayed transfers of care and if quality improvements are experienced by patients and families / /
Support to Care Homes
Support to Care Homes
Support to Care Homes / Proactive support
To identify needs early and support the care homes in managing emerging and ongoing health problems. Not in place yet, two models being explored. / South Tees / Evaluation of Pilot led by South Tees Trust – initially 4 care homes extended to 12 care homes identified with high admission rate. Rapid response nurse attends if anyone at risk of being admitted. An evaluation of the pilot will be carried out and learning shared. Alternative modes of delivery to be appraised including alignment with CHESS scheme. / / /
Care Home visiting and education support service. (CHESS)
Providing urgent response and management of exacerbated illness through protocols and training. / South Tees / A 12 month pilot will commence June 17 to provide Emergency Healthcare Practitioners to cover all South Tees Care Homes as first response for anyone at risk of being admitted to hospital from a care home which includes education and training with care home staff on site including development of I.T application to support clinical processes. / /
Dedicated Medicines Management Proactive medicines optimisation support to Care Homes to improve quality of care and reduce risks around medication use and storage. Posts appointed to, implementation from April. / South Tees / A 12 month pilot to provide additional meds training and support across all care homes will commence April 2017. / / /
Discharge Planning New protocol agreed and developed for transfer of patients between Care Homes within STHFT, includes clear expectations on admission and discharge and a discharge form for Trust staff to complete. My Care Passport developed which a care home resident brings with them on admission to hospital, within the hospital and on discharge back to care homes. This contains all relevant information for that patient. / South Tees / The Passport will be rolled out to all care homes from April 2017. A password system is also being examined with the aim to improve data/information sharing between the trust and care homes. From April 2017 the Red Bag Scheme to transport patients belongings between care home and hospital is also being considered as part of the North East and Cumbria Emergency Care Vanguard meeting group. /
End of Life Training and Support
An additional specialist palliative nurse to improve the palliative care skills of care home staff and provide a higher standard of palliative care for patients, enabling planned care up until death in the most appropriate and preferred place. / South Tees / This is an 18 month pilot commencing April 17. To undertake end of life training to gold standard framework, exploring verification of death training in nursing homes and use of Advance Decisions. / /
Falls Training and Support
Aim to prevent falls within care homes and support staff to effectively manage falls thereby reducing NEAS call outs and unnecessary emergency admissions. A Pilot commenced September 16 delivered through the STFT Falls Team, Coast and Country Housing and Middlesbrough Council’s telecare team (for M’bro care homes). Care homes with the highest number of resident falls resulting in hospital admission are targeted. Assessments carried out by OT with the fitting and monitoring of telecare equipment. Includes education and training for staff including risk assessment and post fall training. / South Tees / Scheme will be evaluated and if successful will be extended to other care homes with high incidents of falls. Additional components including telehealth to be explored. This scheme will inform the wider Falls integrated pathway development which is to be designed and embedded in all settings. / / /
Infection Control
A role to provide support and guidance around infection control in care homes / South Tees / Commence in mid-April 2017. Nurse A nurse has been appointed and will work across all South Tees Care Homes, initially for 12 months / / /
Nutrition Training and Support
Enhanced support to care home residents and staff around nutrition and dietetic support. Aims to identify those at risk of malnutrition and prevent cases through education and training of staff / South Tees / An 18 month pilot will commence in April 2017 to provide additional nutrition training and support, including speech and language input, to all south tees care homes. Public Health will provide the service in Middlesbrough and South Tees Foundation Trust Dietetics team will provide in Redcar & Cleveland. A steering group is up and running with mobilisation starting January 2017 for April 2017 start. / / /
Physio and Occupational Therapist – training and support in relation to moving and handling, equipment, contractures. Proactive and reactive resource. / South Tees / Implement workshops on postural management and identify further training needs.
Facilitate equipment auditsand training with target care homes.
Assessments when identified as part of safeguarding processes with link back to contract and quality monitoring. / /