1. 15th November 2017 alison.watson8@nhs.net
Nottingham City CCG Enhanced Health in Care Homes Vanguard Update for NHS Confed Visit
15th November 2017

2. 52 older people’s care homes
Population covered by the Nottingham City CCG Vanguard: 38
Older People (1567 beds) 12
Dementia
(435 beds) 1 LD
(16 beds)
PDSI
(32 beds)
52 older people’s care homes
providing..
2050 beds
28 residential homes
24 nursing homes
Of which..
Of which..
75% of homes are rated by CQC as 'Good',
23% as 'requires improvement
0% as 'Inadequate'. 2%
Yet to be inspected

3. Please see interventions matrix to what has been implemented where.
Nottingham City CCG Model alignment to the National Care Homes Framework
1. Enhanced Primary Care Support
Clinical pharmacy
Medications reviews of all residents in the top admitting care homes.
Medication reviews of all newly admitted residents across the top admitting care homes
Telemedicine
Telehealth
5. Joined up commissioning & collaboration between health & social care
Shared contracts in place
2. MDT support including coordinated health and social care
Red Bag initiative (146 care homes across Greater Nottingham)
Systm 1 access
Patient Online
6. Work force development
Programme of training provided for care home staff including: restraint, sepsis, nutrition and MUST, wound care, end of life training (including emotional support).
Training being sourced for care home managers
3. Reablement and Rehabilitation
Equipping 3 rooms with bariatric equipment
Training provided for the delivery of chair based exercises.
Sensory and reminiscence bags provided to all care homes
Music tablets ordered and templates being provided to develop personalised play lists.
Additional training provided for activity coordinators
7. Data, IT and Technology
Telehealth – Whzan live in 10 nursing homes
Telemedicine – Clinical hub support via teleconferencing in 26 care homes
Systm1 access- aim roll out from December
On-site Urinalysis – Live in 4 care homes
Internet Connectivity - survey underway of all care homes
NHS mail – working with NHS digital and care homes.
Patient Online – In progress
4. High quality end of life care & dementia
End of life training provided for care home staff.
Managing challenging behaviours and restraint provided for all care home staff.
Please see interventions matrix to what has been implemented where.

4. Timeline of interventions
2016
Sept
Oct
Nov
Dec
Clinical pharmacy began reviewing recently admitted (from own home and hospital) care home residents. Urinalysis rolled out to 4 care homes.
2017
Jan
Feb
Telemedicine rolled out to 10 care homes
Mar
April
May
Clinical Pharmacy at full capacity and begun reviews of all care home residents
Jun
Jul
Clinical pharmacy commenced using the admissions avoidance tool.
Aug
Telemedicine live in a further 16 homes
Sensory and reminiscence bags distributed.
Red Bag roll out across Greater Nottingham.
Telehealth rolled out to 10 homes. Commence training programme for care home staff.
Connectivity survey of all 52 care homes completed. Bariatric rooms to be ready.
2018
Year 2 Evaluation
Please note, the care home nursing team, dementia out reach teams, Age UK advocacy service, and joint commissioning contracts were in place prior to the commencement of the care homes vanguard.

5. Clinical Pharmacy
3 Pharmacists recruited to provide Medicines optimisation and reconciliation to care home residents.
Targeted the highest admitting homes
In Q2 110 Medication reviews completed
48 acute reviews completed of residents admitted to care homes (whether following discharge from hospital or from own home).
62 whole home reviews of other residents in care homes from the start of May (data will be presented on the completed care homes in Q2).
Resulting in:
196 changes to medications
29 changes to medications linked with falls
33 changes to high risk drugs.

6. Clinical Pharmacy Admissions avoidance tool:
The team have been using the admission avoidance tool that has been developed based on the RIO tool.
The tool grades the intervention based on likelihood of avoiding an admission (Level 3 -Likely prevention of a hospital admission, Level 2 = Possible prevention of a hospital admission, Level 1 - No likelihood of preventing a hospital admission)
Data for Q2:
20 Level 3 interventions = admission avoidance saving of £49,840.
64 Level 2 interventions = £15,948.80
Prescription savings = £10,091
Savings for Q2 = £75,879.80– Estimated Annual savings = £303,
Saving per review = £689.81

7. Pharmacy at full capacity
Clinical Pharmacy
The graph below shows admissions from the 10 care homes who have received active pharmacy intervention.
Pharmacy
introduced
Pharmacy at full capacity

8. Telemedicine 24/7 video conferencing to a clinical hub in Airedale
Telemedicine is now in operation in 26 care homes.
Many homes went live middle of August.
July-Sept– 225 calls were made to the service.
We are working with the care homes to understand if the homes are using the service appropriately and also working with the homes that are yet to use the service to promote implementation.
Of the calls, 71 were made within hours, 154 out of hours.
37 of the calls were from nursing homes, 188 by residential homes

9. Telemedicine
Table 1 shows a reduction of calls and a 11% improvement in call: convey rate when comparing Q1 2016/17 with Q1 2017/18. The table also shows a reduction of 32 conveys when comparing the two quarters. Based on a cost per A&E attendance of £151 and a cost per see and convey by ambulance of £188 this equates to a saving of £10,848.
There has also been a reduction of 9 admissions from 72 in Q1 2016/17 to 63 in the same time period 17/18. If we attribute £2.5k per admission this equates to a saving of £22,500.
Table 1: Number of calls from telemedicine care homes to 999 and Immedicare
Care Home
EMAS
2016/17 – Q1
2017/18 – Q1
Call
Convey
Convey Rate
Total
192
122
63%
121 90
74%

10. Telemedicine: EMAS data
In Q1 17/18 the number of 999 calls recorded across all vanguard care homes was at its lowest in the data we have available (top left).
In Q4 16/17 and Q1 17/18 there's a reduction in number of 999 calls and an improved conveyance rate in the homes with telemedicine (bottom left).
In Q2 we rolled out telemedicine to 16 additional homes so we should see more of an impact in the data for all care homes from Q3.
Telemedicine introduced

11. Breakdown of care staff intentions Outcomes and referrals
Telemedicine: Immedicare data
Breakdown of care staff intentions
Jul 17
Aug 17
Sep 17
Total
Caller would have called their GP 40 48 51
139
Caller would have attended A&E or called an ambulance 5 9 4 18
Caller would have contacted community nursing service 2 1
The caller advised they would not have contacted an alternative healthcare provider 16 12 7 35
Not applicable 6
No response recorded 3 10 76 78 71
225
Outcomes and referrals
Jul 17
Aug 17
Sept 17
Total
Outcome
Patient remained in place of residence 69 65 63
197
Ambulance request for patient 7 13 8 28 76 78 71
225
Referrals
Referral to collaborative nursing team 1
Referral to district nurse 3
Referral to GP 5 14 17 36
Referral to general practitioner out of hours service 6 18
No onward referrals 61 58 48
167
Of the 225 calls 197 residents (88%) remained in their place of residence
28 ambulances were requested
In the absence of telemedicine the care home would have contacted the GP on 139 occasions whilst the referrals on to GPs by Immedicare was only 54 saving 85 calls to GPs (10min/call = 12 hours).

12. Urinalysis Piloted in 4 care homes
There has been an overall rise in the number of admissions in these care homes.
There has been no impact on the number of admissions related to UTIs from the 4 care homes.
Review of medications identified increased diagnosis of UTI and increased prescriptions issued in these care homes compared to the same time period

13. Urinalysis Focus group held on 8th November with key stakeholders.
Decision made not to roll to additional homes based on data and national guidance.
Training need of care home staff was identified
“To dip or not to dip” being rolled out to our 4 neighbouring CCGs.
Next steps
Explore options of “To dip or not to dip” roll out across the city.
Develop clear pathway/flowchart and guidance for care home staff around recognising and managing UTIs.

14. Telehealth Live in 10 nursing homes from 1st November 2017.
Care homes take regular observations using the devices.
The results transmit via blue tooth to the hand held tablet.
Generates a score based on the National Early Warning Score system to support escalation.
No data available yet

15. Information sharing NHSmail
We are now starting to work with care homes to support access to NHSmail accounts to enable secure ing.
System1
We are waiting for a National guidance around the Care homes module for System1 prior to supporting homes gain access.
Patient Online
Access to Patient Online will be explored in January.

16. Additional work streams
Sensory and Reminiscence bags
Tablet devices to develop music personalised playlists
Bariatric Equipment provided for 4 care homes
Programme of training for care home staff
Care homes dashboard development
Red Bag

17. Beethoven: Friend or Foe?
Care Homes Dashboard
ALL Care Homes
Beethoven: Friend or Foe?
Functional from July 2017.
Refreshed quarterly
Combines acute, self-reported and quality monitoring data
Can filter by:
Individual care home
nursing/residential
Vanguard/non-vanguard
Client group

18. Future:
Clinical Pharmacists – part of the integrated care homes team that has been commissioned from July 2018.
Care Homes to have direct access to experienced clinicians 24/7
Care homes to be able to communicate securely with partner organisations (i.e. care homes nursing team, acute trust etc.)
Care homes dashboard to be used for quality monitoring and to target interventions