Shires Joined Care Programme

Area of work
Care of older people with complex needs

Project Type
New ways of working

Project summary
A multi professional primary care team in a very deprived area, working with their local social services colleagues, has adopted a Unique Care model and enhanced it to deliver a superior service for older people with long term conditions and complex needs.

Taking an evidence base and then developing a culture in which constant learning, experimentation and risk taking could occur, the team has realised the benefits of a whole system approach.

The 'whole system' has revolved around the patients and their needs, incorporating primary, community, secondary healthcare, pharmacy, social and voluntary care in the solutions. Challenges to excellent communication have been addressed and overcome.

Details of the project/work
Shires Healthcare is a primary care team looking after nearly 15,000 people in an area which is ranked 31 in the bottom 50 (most deprived) local authorities (IMD 2004). Shirebrook, where the programme is located, has 60% more people with limiting long term conditions than the UK average. It had high levels of emergency admissions. A community matron had been appointed and emergencies were slowly reducing. The team worked as effectively as it could with social services but it was recognised that gaps existed. Government papers , "Our Health, Our Care, Our Say" (OHOCOS) and "A New Ambition for Old Age" proposed a more joined up approach.

The trigger for initiating this came when a GP in the practice attended a presentation about the Unique Care model at an Improvement Foundation commissioning event. Further work was done to fully understand the model and he successfully engaged the PCT and social care, where a service manager had already begun to research the model too. The practice had already studied the hospital activity for practice patients, compared themselves to expected figures and other practices and undertaken case study work to try to identify where the gaps in the system might be. The project team then set out to study a potential case-finding methodology but did not find anything which would satisfactorily utilise both health and social care data to arrive at risk levels.

The Aims and Objectives were.
"To expand the freedom of people to live the life they have reason to value" (Amartya Sen's theory of Development as Freedom.(1998) ) ; specifically, to improve outcomes for those patients 65+ most at risk of being admitted to hospital with complex problems involving health and social care with the following results (outcomes) under four objectives from OHOCOS:

• Better preventative services with early intervention
• Increased confidence of clients in self management
• Optimum medicine management
• Adequate social contact,
• More Choice
• Optimum mobility
• Client perception that they are involved in decision making,
• Tackling inequalities and improving access to community services
• Maximise family income
• Patient need is matched to service development,
• More support for people with LT conditions
• Reduction in avoidable unscheduled events for this group
• Targeted use of existing resources e.g. step-up beds.

Patients eligible for the programme were:
OVER 65 and struggling with TWO or more of the following

• Emergency admission to hospital in the last 12 months
• Long-term condition
• Worsening condition/circumstances
• Memory problems/confusion
• Falls
• Issues/concerns about tablets/medicines.

Each patient/carer is involved in the creation of a bespoke care plan to meet their needs.

The involvement of patients, particularly in the “Living with long-term conditions” work, has given the team new insights into patient battles to have the optimum quality of life. Patients agreed to be recorded on video talking about their everyday experience of daily life with their condition and the challenges of having professionals come into the home. This was viewed and discussed at a whole team protected time session. Local specialist nurses were able to discuss with the team how they could further assist by early intervention and support for difficult cases.

Use of video meant that the participants were speaking in their own environment and not over awed by a large number of health professionals. However some patients did choose to participate directly, one recreating a series of consultations with a health professional to demonstrate how he had gained control of his sugar levels. Training in local care homes on choice of place of death was delivered by the community matron and care manager and included GPs, nurses and home care workers. The patient representative in the project team chose to attend and found the session helped him (considerably) with a death in his own family. It has also increased confidence in care homes not to call the ambulance when an alternative plan is in place.

The community pharmacist delivered training for homecare and healthcare assistants in medicines’ management. The social care manager reports a considerable improvement in the 'ownership' and confidence being exhibited by homecare staff in supporting patients to self-care.

The team works closely with other health sectors including the ambulance service, the out of hours service and secondary care where hospital in-reach has been a feature of the community matron’s case management. There is a local scheme to share contingency plans between services.

There is a project manager and members of the project team are representative of the stakeholders including: GP, Community matron, social care manager, patient, community pharmacist, diabetes nurse, DN team leader, senior nurse PCT, social care service manager and area manager, PCT primary care development manager, practice manager, local manager Improvement Foundation

In October 2007 the team took the principles of the Unique Care model and developed a programme for elderly patients with complex needs, ensuring they receive a joint health and social care assessment within 24 hours of referral, resulting in a patient centred care plan, which is then implemented speedily.

Shires Healthcare entitle their project 'The Joined Care Programme' which is a collaboration involving Community Pharmacy, social care providers, GP's, district nurses, patient representation, community matron, and the care programme is co-ordinated by a social services care manager. They created a pathway from scratch to suit local circumstances and, in the absence of a better method of case-finding, worked up a triangulation of data from primary care, social care, and United Health Europe (UHE) Health Numerics-RISC to develop an initial list of patients at risk. However, there have been huge improvements in team communications as the project developed and, by February 2008, professionals were making very effective referrals to the service. The community matron and social care manager have collaborated to ensure that plans are implemented swiftly so as to reduce deterioration in the patient’s condition.

A key feature of the programme has been constantly to monitor and review service gaps which can then be put forward as commissioning proposals or other solutions sought. The community pharmacist was able to highlight medication issues of which he has previously been aware in this vulnerable patient group. During the regular case meetings it emerged that medication errors, inappropriate use of medicines and medicine omissions were resulting in unnecessary admission of patients to hospital. Training needs have been addressed, emphasising the need to risk-assess at the point of prescribing, so medication is dispensed in a form which enables patients to use it effectively. Patients with visual impairment are particularly at risk.

By discussing other apparent service gaps it has been possible to identify services not previously used effectively and the Social Services team report that efficiency and effectiveness have been much improved within existing resources. Service gaps are being addressed by negotiation with the PCT commissioners particularly for cross border patients. The team had welfare rights officer input to try to ensure that the maximum resource reaches the local population.

Recognising there were some training needs in the existing workforce, the team acquired training funds to update and mentor district nurses in long-term conditions management.

The programme was evaluated on data up to October 2008 and is now being bought into the mainstream.

The outcomes
Quality outcomes are described within the previous paragraphs. Based on the agreed target areas, the results and financial statistics are available in separate reports. The headlines are:

• Increase to almost 100% of those supported to live at home
• Reduction by 9.66% of cost of emergency admissions, saving £179,586 in 12 months
• Almost 100% increase in those receiving active case-management
• Time from referral to assessment of less than one working day in most cases
• Achieving preferred place of death in 99.9% of cases
• 100% implementation of plans in the assessment within existing resources

We achieved the objectives in our original plan plus those which emerged as issues during the course of the project and, particularly, valuing the ‘foot soldiers’ who spend more time than anyone else with these patients and offering them training to improve their confidence to be a key person in the process of developing self care Communication has vastly improved and comments from stakeholders include:

DN: “I used to work in this team but have been working elsewhere for a couple of years. I have now come back to work here and the difference in communication is amazing. I know who does what and what is expected of me and know who to go to when I need help”

Community pharmacist: “This programme and being in the project team has meant I can raise issues we have never talked about before”

Social care manager: “We all think we know what each other’s roles are but what we found was that we didn’t and had hugely unrealistic expectations of each other. And we now know much more about each others’ systems”.

Norfolk area social services team arranged with the local team to undertake the care of a patient for whom they held funding and they emailed: “Thank you so much. This was a really slick operation and not what we are accustomed to”.

We are most proud that the project was allowed to be driven from the front line, supported but not dictated by PCT and social care management. It has enhanced an evidence-based model using an ‘emergent strategy’ approach to achieve the aims and objectives for all stakeholders in a short period and released resources over and above the investment so that we can now begin to invest those saved resources in further, difficult to tackle issues for our very deprived population.

The project invested in backfill for the social care manager to give her space to set up the new way of working but, as envisaged, this new way of working is replacing the previous one with better results and no extra cost. The duty officer is no longer receiving any calls for this team when the care manager is on duty and the work of the backfill, funded by the project, is beginning to be scaled down. This suggests it is both self-funding and resource releasing and has produced quality benefits for patients. Other teams are now applying to adopt it.