Caring for elderly and frail people

Date: 12 May 2015

Time: 01:00

Services to support people in the community last winter

NHS Bromley Clinical Commissioning Group (CCG) and the Bromley Council have jointly commissioned a Winter Plan with around £2m of additional funding from October 2014 to March 2015. It will ensure additional support is provided to prevent avoidable hospital admissions and help elderly people get back home as soon as possible. It will also enable them to receive urgent care including rehabilitation and practical support in their own homes. 

There is also a Community Escalation Plan in place. This is a multiagency effort with NHS Bromley CCG, Bromley Council, Princess Royal University Hospital, Bromley Healthcare, Oxleas, social care services, St Christopher's Hospice and Age UK. It is overseen by the local Urgent Care Board Chaired by Dr Essop, a local GP, and Dr Bhan Chief Officer of NHS Bromley CCG. 

Our community plan for winter provided seven key standards to ensure the right capacity to provide health, social care and practical support for people in an appropriate setting to their needs, seven days a week.

Benefits to patients that we have seen this winter

Seven day working

At NHS Bromley CCG, our first priority for winter funding was to get local healthcare working seven days a week. We have begun expanding services that until now ran only during the week (or had some weekend access) to properly cover weekends. These include: longer hospital pharmacy opening hours; all urgent scans requested at the weekend are completed and reported; additional senior decision makers in the hospital emergency department; additional consultants so patients could be discharged at the weekend and increased access to specialist consultant advice every day. 

Of particular success has been Bromley Council's provision of social care assessments. Social workers have been working overtime to increase the number of assessments given on the weekend from five to 10. This means patients can go home on Saturday or Sunday rather than having to wait until Monday.

Ambulatory care unit

Opened in May 2014, this service is at the Princess Royal University Hospital for patients with urgent medical conditions. Patients are referred by their GP, or other services, treated there and leave the same day. In the past these patients may have admitted to hospital. Our view as clinical commissioners (based on clinical evidence) is that when patients need diagnostics, treatment and monitoring, then hospitals are the best place for them. However, not all patients need to go into hospital if the care they need can be provided in a better way.

The Ambulatory Care Unit is staffed by a consultant acute physician, senior nurses and junior doctors and treats around 280 people a month. Thanks to the additional funding an extra 100 people used this service in January 2015.

Medical response team

Bromley Healthcare's Medical Response team provides assistance to patients so that they can receive urgent care in their own home – two hours from receiving the referral.   We have expanded the team over winter with nurses, physiotherapists, occupational therapists and healthcare assistants. These assistants are vital to ensuring we can maintain people in their own homes when they lack practical support with daily living activities. For example if they live alone and need help taking  medication or their condition needs monitoring.  Whilst most of the referrals come from GPs to prevent their patients' admissions to hospital, the service is now taking referrals from A&E. This will help more people get the care they need without needing to be admitted to hospital.  

The Medical Response Team has been seeing around 15 people per day. This has doubled during winter. Many of these people would have been admitted to hospital if this type of home care was not available.

Home-based rehabilitation service

Last summer, we commissioned a new way for patients to receive rehabilitation. There are now 36 rehabilitation beds at Lauriston Nursing Home and a home-based rehabilitation service offering five rehabilitation places every day. This combination of home and bed-based services ensures that local people can access the service that best meets their needs and enables them to regain their confidence and independence most effectively.

Supporting tenants living in extra care housing 

Local GP practices have been working in partnership with the Bromley Council, housing associations, extra care housing managers and tenants to launch a new service that provides additional primary care services in people's own homes. Tenants and extra care housing managers can now call upon a Visiting Medical Officer for additional medical help to manage emergencies in tenants own homes.

Whilst it is difficult to measure the impact of these schemes, we know that patients are being medically assessed, having their medication reviewed, and are working with doctors to develop plans for their care. 

St Christopher's Bromley care coordination

Traditionally, St Christopher's has provided palliative care to patients and families with complex needs. In recognition that that there was a need to coordinate and manage better the care needs of the frail elderly and those who did not fit the criteria for traditional palliative care, the CCG commissioned a Care Coordination Centre.  In its first year of operation, the service has coordinated the care of 386 people. 

With the extra funding over winter, the number of patients receiving care coordination at any one time has doubled from 30 to 60. This has meant that 80% of patients receiving this care were able to choose to die at home, whereas for patients not known to this service, half of all deaths are in hospital. This service is having a positive impact on patients and their families and with more work to do identify patients suitable for the service earlier we look forward to more people being about to benefit.

Dementia and cognitive impairment

Supporting patients and their families who are beginning to experience the onset of cognitive impairment, confusion and dementia is perhaps the biggest challenge we face locally. Bromley has an ageing population and so it is our aspiration is to provide the best dementia care available in London. Unfortunately we are some way off doing this. At the moment, only around  52% of the projected numbers of people with dementia are diagnosed where as best practice is 67%. 

Concerns have been raised by our GPs that receiving confirmation of a dementia diagnosis can be distressing for both patients and their families and needs to be accompanied with the right information, treatment  and support. Fortunately we have learnt from conditions, such as diabetes, that diagnosis leads to better outcomes for patients.

Over the winter we got two specialist dementia nurses from Oxleas to conduct assessments for patients with in residential homes. There is a resident psychologist and increased access to CT scans for patients that need specialist diagnosis. Diagnosis rates improved by 5% in December alone and we are working with Bromley Council, Oxleas and all providers to develop further investment plans in this care for patients with dementia and cognitive impairment, including on-going support for patients.

Mental health liaison service at A&E

People of all ages now have access to additional support from the mental health services if they come to the emergency department in crisis or needing immediate support. The service has doubled its capacity, including provision for children and young people, which had ensured that over 85% of people needing the support of mental health services can access this in less than 2 hours.

Returning home from hospital sooner

One of the main pressures on the NHS is ensuring people get access to good quality personal care. Whilst the national debate has focused on how we pay for social care, we and Bromley Council think commissioning integrated packages of care that combine health and social care across the community is the right thing to do. In this way we can support elderly people who may be isolated or whose family cannot care for them whilst convalescing or receiving rehabilitation at home. 

Fast response personal care package

So far, 100 people have accessed this service. It offers four hours of personal care for up to seven days when a person is discharged from hospital. It enables people to regain the confidence they may have lost during their stay in hospital. 

Intensive personal care package

This winter, 59 people have taken advantage of the intensive personal care service to support their discharge from hospital. This service has provided on average 150 hours of support per person. This level of home support offers local people with a genuine alternative to long-term residential care.

Take home and settle – Age UK

Age UK have for many years delivered a successful Take Home and Settle service. This service can be requested by patients or hospital staff if assistance is required to get home from hospital and to provide good neighbourly support when people first arrive home from hospital. Additional investment will allow this service to grow from its current provision.

Rapid equipment store

Getting access to the right equipment quickly can make all the difference to people leaving hospital. In January, 523 extra pieces of equipment were issued to people leaving hospital. This service is supported by a handy man with a van and therapy assessors.

Non weight-bearing patients

After a fall or fracture, some people require short-term support in a residential care setting before they can start their rehabilitation. Additional funding has made it possible to support up to 43 people to receive this support.

Mental health

There are home treatment teams in place all year round for adults and older adults which allow people with acute mental health conditions to be treated at home where it is safe to do so. In addition the teams can facilitate early discharge from our mental health wards where appropriate.

NHS Bromley Clinical Commissioning Group is the main commissioner of NHS services in Bromley. It works for local residents to plan and purchase NHS services and improve the health of people in Bromley. It is led by local NHS doctors and covers a population of over 326,000 from Beckenham to Biggin Hill, Elmers End to Orpington. It is committed to helping people live longer, healthier and happier lives.  At the same time, it is striving to meet the continuing challenge of keeping spending on unplanned hospital activity in check and managing demand. 

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  • Summary:

    NHS Bromley Clinical Commissioning Group (CCG) and the Bromley Council have jointly commissioned a Winter Plan with around £2m of additional funding from October 2014 to March 2015. 

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