sustainability and transformation partnership area: bath ... · virtual word (woc)(v) pn community...

#NHSAgeingWell

Sustainability and transformation partnership area: Bath, Swindon & Wiltshire

What services do you currently have in place at different stages along a person's 'journey of frailty', from prevention/risk reduction all the way through to end of life care?

Phase of Care Proactive Routine Responsive

Deg

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of

Frai

lty

Mild

St. Johns – ballet activites Waitrose – ‘slow shopping’ Falls and balance clinic ‘Steady steps’ programme Befrienders – Alzheimer’s society / Age UK

Care and repair CGA Pendant alarm monitoring Telehealth Carers hub

Falls response car SWASFT Home first Enhanced discharge Therapy services - OT & physio

Moderate

Active ageing Ageing well Local health authority / public health Proactive care #endPJparalysis

Fire safety checks - Smoke alarms- Advice guidance

Consultant connect Frailty medical nurse

CITT teams Mental health support Frailty flying squad

Severe

Respect / TEP Palliative care Conversation project GP contract

Practitioner (community) Dementia coordinators

(across mild, moderate and severe frailty)

GP practice MOT Hospice care (incl. symptom management) Community matron

(Acute care/ hospital)

Bath, Swindon & Wiltshire STP area #NHSAgeingWell

What actions can be planned for the next 12 months?

Elective admissions – pre-op optimisation in surgical specialities (pre-hab) (community CGA)

Community Frailty Flying Squad

Frailty screening – Swindon to use Dorset model

Frailty in reach to support other clinical teams

- Cluster MDT model- Care home MDT

- RESPECT

What are the challenges to implementing these actions?

STP alignment

Funding

Expectation to save ££s

Changing culture

National / STP promotion of enhanced summary care record

What support is needed from other organisations (national and local)?

Good communication

Collaborative approach

Share good practice

Supporting the tests of change

STP – wide FLOW

Further changes to GP contract (enhanced)

One IT system

Bath, Swindon & Wiltshire STP area #NHSAgeingWell

Name

Victoria Nelson

Nic Aplin

Gemma Quick

Catherine Phillips

Patricia Gordon

#NHSAgeingWell

Sustainability and transformation partnership area: Bristol North Somerset South Gloucestershire (BNSSG)



Deg

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of

Frai

lty

Mild

VSO’s Leg club model Red cross Fire services Community navigators Active ageing GP’s / community matrons Falls Team Therapy COT + PTD SALT + diet PE + LEAP Pharmacy Exercise on PX Day Centres Carers Support

Red cross / VSOs Community nursing services Dementia navigators Active ageing S.SGPsSalt + dietTherapy – OT / PhysioPharmacyCarers supportContinence

Ad clin pract Red cross Clinical hub Rapid response / React ED / CPEL Home from hospital Social Services MH EOL/ Hospice Carers support Pharmacy Continence IDS Falls D2A Ambulance Therapy

Moderate

Fire services Community navigators Active ageing Frailty service N. Somerset Salt + diet P.E. + Leap Day Centre Carers support Residential CH Team Community matrons Falls team Therapy (O.T + PT) Pharmacy Exercise on PT

Red cross/ VSOS COUS Specialist services Comm nursing Dementia navigators Active ageing Frailty service N. Somerset Rapid access (acutes) Frailty MDTS S.SMHGPsSalt + dietTherapy OT/ physicsPharmacyDay centresContinenceCarers supportExercise on PX

Comm matrons/ Ad clin pract Clinical hub Rapid response/ react ED/ OPEL / Acute Assers unit Frailty team South Glos Home from hospital Social services MH EOL/ hospice Therapy Pharmacy Continence Carers support APT IDs Falls D2A Ambulance

#NHSAgeingWell

Severe

Fire services Salt + diet Community matrons Frailty service N. Somerset/ MDTS Residential CH Team GP/ Community matrons Therapy (OT +PT) Pharmacy Carers support

Red cross / VSOs Specialist services Comm nursing Dementia navigators Community matrons/ AD clin pract Frailty service N. Somerset Rapid access (acutes) Frailty MDTs GP’s S.SMHTherapy OT/ physicsPharmacyCarers supportSalt + diet

EOL/ hospice Clinical hub / SPA Rapid response/ react Comm matrons/ Ad clin pract ED/ OPEL / Acute Assers unit Frailty team South Glos Home from hospital Social services Social services MH Therapy Carers support APT IDs Falls D2A Ambulance

Bristol North Somerset South Gloucestershire (BNSSG)

#NHSAgeingWell


Information sharing – develop a directory of services – electronic, for healthcare professionals, care navigation for patients, project work to Map.

Agree whole system outcome measure

- unify offer to failty – alignment across BNSSG (eg. Trust assessment)- shared vision

Patient + public involvement in above


Communication – I.T. eg. Acute community – different language of assessments

Finances – different commisionary bodies historically

Needs based care (being able to wrap services around pt)

Training needs for frailty (consider videos etc)

Breaking the cycle – moving from reactive to proactive

*Dedicated time to transform

Buy in from executives / STP etc


Opportunity to showcase good practice & share – networking platform

Good data

National profile & awareness eg. Campaigns – NHSE

Link in with other AHSN

Engage other parts of the system less represented eg. GP, Social, Public health


#NHSAgeingWell

Name

Nigel Jowles

Arvind Kumar

Sandra Akintola

Emma-Kate Reed

Jarrod Richards

Charlotte Kane Sabrina McAndrew

Denise Chambers

Allanagh Hart

Karen Field

Ben Piper

Vee Spandoni

Rachael Morris-Smith


#NHSAgeingWell

Sustainability and transformation partnership area: Cornwall Green = RCHT | Blue = CPFT (community) | Led voluntary | Group work (v) = variable across the county



Deg

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of

Frai

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Mild

Centipede clubs (v) PN Community makers Comm. Rehab Voluntary organisations (v) Memory cafés Health promo service (v) Merlin (ms charity) Living Well (v)

Health promo service (v) Falls service Specialist nurses PN Focus on frailty falls Facebook page Telecalls

GP Home first D2A SWASFT STEPS Community nurses Acute GPs Acute GPs ACAH

Moderate

Virtual word (woc)(v) PN Centipede clubs (v) Community makers vol. sector Comm. Rehab team Voluntary organisations (v) Memory cafes Health promo (v) Merlin (ms charity) Living Well

Falls practitioner Frailty nurses / CGA Therapies / frailty MDT Community matrons – case mgt Specialist nurses End of life spec nurses Falls clinic ® Community nurses Falls service PN comm. Rehab PCP

Silver phone – geriatricians Falls practitioner OPAL unit Frailty nurses/ CGA Therapies / Frailty MDT Liasion (Onward care) Acute GPS Falls/ eldercare clinic STEPS Red Cross 24 hr rehab end PJ paralysis ACAH CMS Home First D2A SWASFT

#NHSAgeingWell

Severe

Virtual word (woc)(v) PN Community makers. Vol sector Comm. Rehab team Memory café Health promo (v) Merlin (ms charity) Living Well CFT Frailty Strategy RCHT Frailty Strategy

Falls practitioner Frailty nurses / CGA Therapies/ frailty MDT Community matrons – case mgt Comm. Rehab Memory clinic PCP – PN Communist spec nurses. Telehealth End of life spec nurses Falls service Comm. Nurses Dietetics (v) Variable across the county

SILVER PHONE – geriatricians Falls practitioner OPAL unit Frailty nurses / CGA Therapies/ Frailty MDT X Liason (Onward care) Falls/ eldercare clinic CMS Home first D2A SWASFT 24 hr rehab end PJ paralysis STEPS ACAH Red Cross

Cornwall

#NHSAgeingWell


CPFT

Rapid response in crisis team (community)

Falls pathway

MDT integration

Delirium pathway

Local point of access

Core precision for frailty across county

PCP across county

Inpatient falls prevention

TEST healthy ageing clinic

Explore opportunities for healthy/ active ageing

Embed silver phone RCHT

Recruit and embed front door clinicians (strengthen front door MDT) Frailty nurses/ specialists/ medics

Patch geriatrician MDT hot clinic

Growing relationships – integration acute/ comm. Therapy

Teams – develop on discharge within 72 hrs

Trusted assessor for care homes


Capacity in team to lead, and entrust changes in practice, 1 lead for Frailty across system with no support or admin

Money does not follow the patient

IT. No shared platforms, not intuitive, governance

Recruitment is a challenge, not commutable due to distance to travel

Culture and history


Cornwall

#NHSAgeingWell

Name

Clare Rotman

Narissa Kelland

Fern Elkin

Laura Wesson

Naomi Wakely

Magda Morgan

Kerry Crowther

Marie Prior

Project management / admin supoort

Networks

Investment in the right places

Time

Learning proven models – not reinventing the wheels

“Pinching with pride”

Localise learning – a lot of very good conferences but difficult to attend London or North of country due to cost, releasing staff to attend

South West Frailty network resources| platform to share

Time to meet networks / colleagues locally / permission to practice and attend

Cornwall Fire service

Nationally accepted definition for frailty

Challenge national policies

Cornwall

#NHSAgeingWell

Sustainability and transformation partnership area: Devon



Deg

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of

Frai

lty

Mild

Medication reviews Falls assessment Fire services AGE UK Befrienders Exercise groups League of friends GP

GP Practice nurse Community nurses AGE UK Falls nurse Parkinson’s nurse MND Nurse Specialist nurses Stroke nurse Ambulatory nursing clinics Community hospitals

Community nurses MAAT SWAST D2A RADS – rapid assessment discharge service GP Rapid response

Moderate

Voluntary services Community connectors Police Befrienders Community matrons Continence nurse GP

Community nurses Police GP Community pharmacists Voluntary services Care agencies Memory clinic Specialist nurses SALT Ambulatory nursing clinics

Social care reablement MAAT – medical admission avoidance team Police SWAST D2A RADS Intermediate care beds GP Rapid response

Severe

Community matrons Complex health and social care teams (Core group) Continence SALT GP

Core group Intermediate care Marie Curie CCT GP

Electronic Frailty Index Core Group

Urgent care response Intermediate care GP MAAT Marie Curie SWAST Crisis team Hospice D2A RADS

#NHSAgeingWell

Torbay RADS

Dawn Thomas

Louise Williams

Exeter Community

Karen Tetley – Team manager

Bonita Elworthy

Karen Riggs Matron

NEW Devon

Linda Haynes RGN

Marie Curie

Rapid response

Devon

#NHSAgeingWell

Name

Linda Haynes

Dawn Thomas

Louise Williams

Karen Tetley

Karen Riggs

Bonita Elworthy


Shared IT systems access to share information

Integrated services

Standardise documentation – AX once

Develop SMART objectives – improve existing work / services


Information governance

Existing ‘process’

Resources – people and financial


Communications between services – constructive working relationships

Eg. Primary Care and Community services

Community and Acute

Devon

#NHSAgeingWell

Sustainability and transformation partnership area: Devon 2



Deg

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of

Frai

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Mild

Medicine R/V’s within care homes Flu clinics Carers/ providers Frailty scores to map services AGE UK | Vol. services | housing Wellbeing services Library Public health / media/ churches day services Community transport

Annual R/V’s of long term conditions – specialist clinics Integrated MDT DN & CTT Dementia services O/P geriatric AX Caring for carers Dementia day service Singing for the brain Memory café and lunch clubs

Falls clinic/ service DTA / reablement Rapid response – A&E CCRT CCOMM. Crisis response team AC@H (Acute care at home) AAU (Acute care assessment) SWAST ESD Continence clinics Equipment provision Rehab / comm. Hospital Red Cross Memory service

Moderate

Flu clinics Care home promotion of H&WB Befriending services Comm. Transport Churches Day services Dementia action alliance Carers Fire services

Integrated MDT DN & CTT Long term conditions Dementia services O/P geriatric AX Care providers Respite Dementia day services

DTA/ reablement Rapid response CCRT AC@H AAO SWAST Memory service ESD (early supported discharge) Red Cross Continence clinics Equipment provision Rehab Placement in a care home

Severe

GP screening Flu clinics Care home promotion of H&WB Comm transport Carers

Integrated MOT DN & CTT Long term conditions Continence AX Care providers

DTA Rapid response CCRT EOL TEAMS AC@H

#NHSAgeingWell

Name

Anna Fort

Maria Kneller

Kylie Stonehouse

Amiel Celocia

Jon Green

Julian Elston

Fire service Respite AAU SWAST Red Cross Equipment Provision Placement in a care home

Devon 2

DEVON 2 STP #NHSAgeingWell


STP wide frailty strategy and local plans for implementation – setting of terminology ie. Service names

Commitment that any interface Rockwood frailty scales used

Acute setting – delirium screening for all patients

Promotion and training of our service


Terminology/ standardised assessments

Getting people on board – GP / Community / Social services / Acute settings

Resources

Sharing of information between services

Engaging all clinicians

Access to community services across Devon & Cornwall as well as Plymouth


SWAST referrals into AAV

SPoA for SWAST for ones not admitted – STP wide

Sharing of information – collaborative governance


Anna Fort

Maria Kneller

Kylie Stonehouse

Amiel Celocia

Jon Green

Julian Elston

#NHSAgeingWell

Sustainability and transformation partnership area: Devon 3

Name

Michelle Langrishe

Hannah Squires

Liz Bombieri

Debbie Stoodley

Helen Ruse

Caroline Barrett

Stephen Spratling



Deg

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of

Frai

lty

Mild

Social prescribing Dementia nurse MDT clinic

Rockwood scale EFI

Community matrons + dementia admiral

Moderate

Community matron / nurses Falls Social prescribing Dam pharmacist MDT clinic falls

Rockwood scale Acute – comm. EFI Virtual ward/ core group Community therapy Falls team

CCRT AAU Dementia nurse Pharmacist Frailty AX @ A+E

Severe

Falls team Hospice MDT clinic Hospital @ Home TEP / contingency plans

EFI Community therapy Community matron Hospice

CCRT AAU Hospice Hospital@Home / AC@H Frailty AX @ A+E



Identification of frailty

1. Same tool2. Information sharing

Training | Commitment | Changing culture

Contingency planning – single care planning – across boundaries of care

Develop social prescribing system


How information can be shared across IT systems – information data warehouse

Changing culture

Forward planning

Managing expectations / language

- Staff- Family

- Patients


Standardisation nationally/ regionally/ local directions for frailty

Self management – national drive

Building resilient 3rd sector market

Rotations across organisations


Name

Debbie Stoodley Helen Ruse Caroline Barrett Hannah Squires

Liz Baobien Michelle Langrishe Stephen Sprattling

#NHSAgeingWell

Sustainability and transformation partnership area: Dorset: Local / Dorset Wide



Deg

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of

Frai

lty

Mild

Community Rehab – falls

Balance Escape Pain

LiveWell (PH) Preventive and LivingWell

Activity Group (North)

Community Matrons

Heath & social care Co-ordinators

Moderate

Dorset Community Comm Malnutrition Pharmacist Specialist PropRoom2 Practitioners (MUST) Community

Community rehab team EZEC

Memory service (GP referral) MyM Health

Telehealth & Telecare RACE Clinic

Community rehab team Acute hosp at home (West)

SWAST Integrated hubs Social services

ESD Urgent care

Improved access to GP services Community hospitals

District nurses + comm. Matrons ICSD Severe

Everything: Dorset care record | Dorset Frailty Toolkit/ DCP | Voluntary agencies | Adult access | Primary care | SALTs | My Life, My Care |

Enhanced care home prop | Red bag’s for care homes | Frailty training | NRS equipment | Older people’s assessment units | Palliative care

teams| CHS | Research CRN | Trusted practitioners (Acute)

Dorset #NHSAgeingWell Consistent approach to the recognition, assessment and care planning to recognise where patients are on the frailty continuum


Rollout and embed the Dorset Frailty Toolkit and care plan – consistent approach

Access to clinician by paramedics to provide devise ie. Conveyancing the pt.

How to care needs provide for short term need (e.g. care in hospital)

Fire service and paramedics able to refer patients to hubs (using health and social care coordinators)

Improve links with discharge teams

United CGA across primary / community / acute

Research

Consistent pathways & outcomes across Dorset – common expectations

Advanced care planning

Discharge planning


Resources / staffing levels / variative across county – equality of service

Rural vs. urban

Out of country boundaries – accessing services

Lif live on a border – patients house a worse deal

Varying apendas in the different localities – issues with consistent county-wide roll-outs – improve partnerships


“Real” “live” training on system 1 modules

Balance of contractual obligations vs. implement of change (block contracts)

True pooled budgets – locality not service based

NHS funding vs. “ability to pay” social services – how to resolve (national issue)

Dorset #NHSAgeingWell

Name

Andrew Dean

Laura Godfrey

Sue Bridge

Vikki Tweedy

Jane Thomas

Chris Connell

Sarah Morston

Sara Froud

Brad Rootes

Kathy Wallis

#NHSAgeingWell

Sustainability and transformation partnership area: Gloucestershire



Deg

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of

Frai

lty

Mild

EFI Rockwood Clinical assessment Healthy ageing/ exercise Community wellbeing service Fire service MDT – primary care Care coordinators Active Gloucestershire – HPA Risk strategy Memory café Health loading + PAM Dementia cafes

Wellbeing coordinators Care navigators Housing support office Telehealth / telecare Bone health + MSK Specialist services MDT care home support team

Enhanced discharge service

Moderate

Fire service PN-ANP MDT Personal health budgets

Community dementia nurses – pilot CGA Falls service GP + PN Leads – HCA PN ANP Frailty matrons + Community geriatriciansMDT

EDS/ OPAL /RR

Severe

MDT CGA ‘my goals’ ‘me at my best’ PLANS GP + PN heads Frailty matrons Community geriatricians MTD

Gloucestershire #NHSAgeingWell


Training – health coaching, understanding of frailty, raising awareness – e-learning package

CPG – Frailty – starts next couple of months – mapping of projects supporting frailty

Joining up local services and delivering a consistent approach to frailty in each locality

Eg. Linking RR + OPAL

Sharing – Pinching with pride


People/ staff/ organisations that do not understand about Frailty

Patient / carer expectations

Getting everyone working in the same way

Different IT systems

Acute – not able to see information about PT coming in – no visibility in system (track care)

How to link in with voluntary sectors

Breaking down boundaries

Ownership!


National

Clear definitions – use of terminology to be consistent ad mean the same thing across the country

Recognised e-learning package to raise awareness – across all services

Centrally – support with core competencies

Local

Support to develop a self- rockwood score and recommended actions for each level eg. Levels 1-3 – self, care management, plans, equipment, wellbeing, mentalhealth etc.

Challenge national policy

Nationwide campaign

Platform – South West

Gloucestershire #NHSAgeingWell

Name

Jane Haros

Ian Donald

Helen Ballinger

Jackie Hagley

Terri Selby

Sandra Yates

Trudi Walker

(Hein Le Roux)

#NHSAgeingWell

Sustainability and transformation partnership area: Somerset



Deg

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of

Frai

lty

Mild

Identification Cross county working Advance care planning FoPAS RHSS IRT Memory clinic IDS GP

Reassessing – medication R/V falls risk Health coach Community pharmacist

TEP county wide DNAR + TEP Interagency working

Moderate

CCG care home team Complex discharge ANP

CNS Paramedics

Symphony Social services Discharge to assess District nurses

A+E Trauma nurse Stroke nurse Mental health EOL discharge nurse Marie Curie

Severe

Somerset #NHSAgeingWell

What actions can be planned for the next 12 months? Hospital – managing frailty service

- Set up frailty beds – expand fopas service 7/7 working- Admission avoidance- Increased knowledge on community services- Red bags- Ward to take ownership- GP – FRAX – osteoporosis- Increase care planning- More home visits- Improve links between acute/secondary & voluntary


Resources and time – home visits

Staffing

Equipment

Funding

Cultural change

Expectations of patients and relatives

Changing policies and procedures – engagement of services/ family | communication


Social services – government

NHS England

Local MP

NHS Improvement

Investment for micro providers

Trust board

CCG

Integrated agencies

Somerset #NHSAgeingWell

Name

Sharon Field

Anita Howe

Jacqui Dally

Jenny Perris

Darren Cox

Vikki Vose

Cathy Fone

Rebecca Sutton

#NHSAgeingWell

Sustainability and transformation partnership area: Somerset 2



Deg

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of

Frai

lty

Mild

Health coaches Dementia service

Dementia service Community mental health teams Older people

Dementia service

Moderate

Taunton and area wellbeing service

District nursing Sompar complex care hubs FOPAS – acute hospital OPAL – acute hospital District nursing

Taunton and area wellbeing service

South Sompar complex care Severe

Somerset 2 #NHSAgeingWell


Undertake a mapping exercise to identify services and inequalities Identify gaps and overlaps in services and plan how to fill them Understanding “what’s out there” networking A focus on person centred care – via an “information gathering” process with involvement from service users


Communication between agencies – lack of continuity – formal IT and informed

Funding

All agencies are protecting own resources as they are limited – resulting in service users being ‘passed around’

MDT discussions to ‘replace’ referral systems to individual services


Nerve

Leap of faith

Bravery

Money for project team/ facilitators to make change


Name

Helen Hughes

Marie Spink

Lyme Carey

Sue Payne

Kay Griffin

Helen McEvansoneya

Jeremy Martin

#NHSAgeingWell

Sustainability and transformation partnership area: Somerset: CMHTs, Primary Care, IRT

Milbrook Community, Equipment Services Emma Norton, based at Magnolia House



Deg

ree

of

Frai

lty

Mild

CAB Better living Symphony Health coaches Stay strong, stay steady Village agents Voluntary services Fire safety checks

Community care agents Carer support (HMH)

OOH ||| services

Moderate

Referral to specialist services eg. Dieticians Home first Continence services DNs FOPAS Red gross Support at home Safe guarding IRT

RUSS POPS Consultant and urgent connect Interweave dementia specialist service (Yeovil) OPAL #NoFPathways SWAST Fire services EDRed Cross

Severe

Somerset: CMHTs, Primary Care, IRT #NHSAgeingWell

What actions can be planned for the next 12 months? Implement a frailty pathway. Strategy. Standardisation of identifiers. Introduce comprehensive assessments. Education/training – frailty – public message. ACPs. Shared e-documentation. Individualised care plan at patient’s home – for use by all – one folder.


Technology – data sharing. Myth busting (TEPs, DNAR)

Central co-ordination at CGAs

Financial

Avoid duplication


Networking. Building relationships. Understanding roles and areas of expertise.

Data. Patient participation.

#NHSAgeingWell

Name

Sarah Bevan

Katy Richards

Sandra Firth

Fiona Grant

Jenny Pickhaver

Jane Jacobi

Susie Davis

Somerset: CMHTs, Primary Care, IRT

#NHSAgeingWell

Sustainability and transformation partnership area: Somerset 4

Name

Andrea Trill

Clare Boobyer-Jones Patricia King



Deg

ree

of

Frai

lty

Mild

Health connectors / coaching Wellbeing advisors Village agents Micro providers 3rd sector – AGE UK, Red Cross, British Legion Day hospitals – local community groups Exercise & prescribed Singing for brain

Clinics for chronic disease Memory clinic Falls group Literature Signposting on discharge Voluntary sector IRT & FOPAS OPAL Service

Moderate

Partners in care Living better projects Frome Symphony project and South Somerset Activities coordinator Home first

Speech and language therapy Complex core meetings Carer support

Jet team Advanced care planning Palliative care team/ EOI team

Severe

Care plans Housing Employment support Homeless Dementia alliance Dieticians Police Fire service Churches Neighbours and family

Housing Homeless MH beds in NH Community pharmacies Dieticians MH support staff Police Complex care teams and hubs

IRT Homeless TEP Forms Homefirst Taunton draft piper alarm SWAST IDS intensive dementia support Dieticians Police

#NHSAgeingWell

Sarah Mead

Anita Turner

Katie Hart

Shaun Charthew

Liz Harper

Beth Blackwell

Fiona Devonport

Debbie Bennett

Somerset 4



Somerset frailty group – frailty focused group

Standardised frailty template across country – nationally

M.D. community frailty hub – including partners + 3rd sector

With identified functions – outcomes (building on what’s already there) might care

Using technology adorable

Frailty link practitioners

Rapid response / hospital @ home / rapid access clinics / night care


Technology

System communicating

Human resource

Funding

Scale – coordinating

Collaborative working

Integrated health and social care

Budgets linked

Integrated care planning

Pro active discipline – end of life



Name

Sarah Mead

Anita Turner

Katie Hart

Shawn Carthew

Liz Harper

Beth Blackwell

Fiona Davenport

Debbie Bennett

Clare Boobyer-Jones

Andrea Trill

Patricia King

National overlook at data – what has helped in other areas

Education. Support

Organisational leaders to be brave!

CHC conversations / fast track

sustainability and transformation partnership area: bath ... · virtual word (woc)(v) pn community...

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