1. Suffolk Care Homes An Integrated Approach
Lee Taylor – Transformation Lead
West Suffolk Clinical Commissioning Group
16 October 2014

2. Context The Health and Wellbeing Board strategic outcomes
Suffolk residents have access to a healthy environment and take responsibility for their health and wellbeing
Older people in Suffolk have a good quality of life
CCG priorities particularly relevant to the care homes landscape
Improve the health and care of older people
Improve health and wellbeing through partnership working
Demonstrate excellence in patient experience

3. Objectives to support the health and well-being of Suffolk residents
Aim to improve quality and safety standards across care homes in Suffolk and create a network of support through a whole system approach
To promote integrated delivery systems between Health & Social care
Ensure that an integrated approach is employed to:
Improve clinical care
Reduce admissions to hospital
Reduce call outs to OOH
Reduce ambulance call outs
reduce average length of acute bed stay
increase number of people reporting positive recovery and reablement
improve the ‘advance care planning’ process – increase in Yellow Folder issue
Work with care homes with the highest admissions to West Suffolk Foundation Trust, Ipswich Hospital Trust & Cambridge University Hospital

4. Key Facts 137 Care homes across East and West Suffolk
2,738 A & E emergency attendances 2013/14 represents 5% overall activity across east and west Suffolk
Year to date (14/15) 4.78% overall activity across west and east Suffolk
1/6th ambulance call outs are to care homes
Top conditions for unplanned admissions from care homes
UTIs
Lower Respiratory Tract Infections
Pneumonia
Tendency to fall
Fractured Neck of Femur

5. Proactive Care Services
UTI
Developing prevention and support guidelines for care homes
Work on-going to understand blocked catheter challenge
Admission Prevention/COPD/Pulmonary Rehab teams
Admission Prevention Service – COPD team enhancing their access and availability
Increased general practice linkage
Enhanced ambulance service access
Falls assessment and management
Increased assessment opportunities between General Practice, Suffolk Community Healthcare and East of England Ambulance Service NHS Trust
West Suffolk Fracture Liaison Service
MDT approach supporting General Practice and hospital
Actively follow up fracture patients ensuring adequate bone health medication
Lifestyle advice

6. Suffolk Care Homes Group
Multi-organisational group with the overarching aim to support the health sector
Care homes, CCG, Adult Community Services, Acute Trust, Pharmacist, Ambulance Trust, Primary Care representation
Operational group to support activity across Suffolk specifically in relation to care homes
Linked into a wide integrated governance framework across West and East Suffolk

7. East Suffolk West Suffolk Ipswich and East Suffolk System Forum
West Suffolk System forum
Ipswich and East Suffolk Urgent Care System Group
Suffolk End of Life Education Group
Integrated Care Steering Group
Integrated Care Workstream
Integrated Care Operational Forum
Care Homes Group
Care Homes Clinical Support Manager
(WSFT)
Quality Functions
Operational Pathways
Patient/customer experience
Visits/
inspections
Training opportunities/workforce
Data dashboard
Enhanced services
Assessment tools
Pathways mapping

8. Quality Functions
Develop fluid working practices between health and social care to enhance knowledge around inspections and visits
Development of a combined self-assessment tool to assist care homes
Develop integrated training opportunities for care providers
Wider Suffolk workforce development programmes
Falls awareness training
Review patient / customer experience for ‘360 review’
Development of a Statement of Intent - a visual commitment to integrated work by health, social care and care homes

9. Operational Pathways Development of a data dashboard
Assist the sector by understanding on-going challenges
Identify training opportunities for all
Linking information available from Acute Trusts, CCGs and SCC
Proactive approach with primary care to support patients in care homes and establishing links to agencies such as ambulance to ensure our patients receive the right care, in the right place, at the right time
Multi-disciplinary approach to support an individual patient
Proactive Care
Weekly ward rounds – GP and sessional pharmacist
Medication reviews
Falls assessment
Vaccinations
Improved patient experience
Patient shared care plans to ensure comprehensive assessment

10. Operational Pathways
Establish pathway efficiencies and blockages through close review of planned care, urgent care and discharge pathway interactions
Understand most common areas of concern
Build resolution in consultation with the sector
Discharge workshop – early outcomes
Review discharge processes from the acute
Review of medication TTO processes
Work towards a proactive discharge process
Acute Trusts and care homes to be clearer on expectations
Increase confidence levels to improve pathways and patient outcomes
Care Homes Clinical Support Manager
Based in the West Suffolk Hospital
Link across care homes, community health services and the acute

11. Lee Taylor – Transformation Lead West Suffolk Clinical Commissioning Group