- bringing health and social care together The Frailty Project Focus on integration - bringing health and social care together Dr David Tideswell CCG lead for frailty / Dr Sarah Zaidi clinical lead for Frailty Lead provider (SEPT)

The frailty project and integration Bringing health and social care together at all key patient/ professional interfaces . Includes acute trusts and urgent care settings , single points of access for community services ,specialist community services and clinics ; and in primary care including GP practices . Maximising benefit for the frail person at risk of crisis where care coordination , data sharing and multidisciplinary teams working together make key differences in care experience , care delivery and improving patient outcomes.

How - what should we be doing ?? Evidence (NHS England 2014) Identify frail cohort - know who our Frail patients are. Improved access to Comprehensive Geriatric Assessment (CGA) Focus on integration - Health social care and mental health - develop practical system wide multidisciplinary team working Single points of access for specialist key services across health and social care Work to support continuity and enable right level of care delivery at the right time and in the right place ---Care closer to home where possible

Previous Picture Primary care Social care CRISIS Unplanned admission Community NURSING Specialist Care

Integrated working Patient Primary care Community nursing Specialist care Community nursing Social care Primary care GPs Working and communicating together

It's starting already Bare bones of practical integration are starting to be built over recent winter period 2013/14. Front door of A&E integrated CARS team : social worker, old age mental health crisis nurse and CARS nurse working together to assess and plan holistic community care support for frail persons with multidisciplinary needs (7 days a week) . Access to rapid response social care services in A&E and Rapid access community clinics . Social care professionals and information systems are now integrated into the single point of access ( ISPA) and also integrated into community beds for improved more seamless discharge planning. Integrated reablement service is now available direct for persons in the community (via ISPA ) delivering both care and enablement input aiming to promote improved independence , better rehabilitation and prevent premature decline.

A lot more to come- Phase 1 - things we hope to see this summer 2014 End of life care pathway development : aiming to proactively identify persons who are in need of advanced end of life care planning and to provide more seamless care delivery in order to better support persons to achieve their preferred priorities of care and preferred place of death. Care home support teams development : Aligning enhanced specialist community nurse teams integrated with end of life care coordinators and dementia liaison nurses to improve support, provide training and educate care home staff to deliver improved care and have improved awareness of common issues affecting persons in long term residential care settings. Falls prevention service: integrated team of professionals including physiotherapists OTs ,community pharmacists and nurses for more comprehensive falls prevention input. Enhanced case management in the community by matrons :additional recruitment of frailty matrons who will be able to work alongside social care professionals, mental health services , end of life services , ambulance teams , with support from community geriatricians and input from patients GP for the most complex cases eg persons suffering with repeated frequent crisis. Aligning social care support to GP practices to support integrated MDT working in primary care allowing for more effective advanced care planning and management for frail persons who have multidisciplinary needs.

Empowering GPS to retain responsibility for management decisions and care coordination but with support when needed. Meeting rising demand and managing workload and resources more effectively through integrated team working . Expanding skill mix (enhancing professional development) through working with other disciplines and forming real practical working relationships with other disciplines( including social care professionals) . Reduction in requirements for multiple (potentially avoidable) contacts per patient , especially in potentially time consuming settings (eg home visits). Easier , simplified , more timely access to more fit for purpose and higher quality multidisciplinary services (eg falls prevention , reablement ,end of life ,mental health, specialist geriatric support etc) Assistance / facilitation in meeting targets for required reductions in avoidable non elective admissions , specialist out patient referrals , prescribing etc. Financial opportunities ?? - ability take up any new / emergent enhanced services for frail populations .? Eg Avoiding unplanned admissions DES.

Next steps for primary care ? Identify frail cohort through simple yet effective risk profiling methods (Unplanned admissions DES) Monthly MDT working with dedicated social care attendance and support aligned to GP practices for more seamless and effective holistic advanced care planning. Care homes support End of Life pathway development Locality based approach working with Stellar health and Uttlesford health

Points of contact CCG: Dr David Tideswell CCG lead for frailty davidtideswell@nhs.net Lead provider frailty project team : Dr Sarah Zaidi ( Clinical lead for frailty) sarah.zaidi@sept.nhs.uk Heather beach ( frailty project Director ) heather.beach@sept.nhs.uk