1. The Kings Fund and Pioneer Communities
Kernow CCG Governing Body
June 2013
Joy Youart

2. Case for change Increasing demand from older people
Unsustainable in current system
Patients not seen in most appropriate place
Avoidable delays
Continuing healthcare over-subscribed
Leadership summit has prioritised
Older people =
80% of GP activity

3. Kernow one of 10 national learning sets
Learning and sharing ideas, best practice
Clinical leadership
Influencing national policy
Large scale, fast-paced change
Details
5 sessions of shared learning at the Kings Fund
3 days on-site time from an expert from the Kings Fund
A workshop on integrated care for older people for clinicians and operational staff

4. Support older people at home Enhanced support at home
Frail Elderly Pathway – Care standards (time based)
Self care
Input in acute setting
Support older people at home
Enhanced support at home
Support Older People at Home
Manage Crisis Effectively
Manage step down from acute effectively
Enhanced support at home
Self care
All standards relate to patients assessed as being ‘frail’
Home/care home
Crisis
Acute
Trf of care
Home/care home
Std H1. All patients remotely identified as an emerging risk (by e.g. the Devon tool) will be assessed* within 7 days
Std C1. For all patients identified as being at risk of admission to an acute hospital, an assessment *will be initiated within 2 hrs of the request
Std A1. On arrival in ED / admissions unit, all elderly patients at risk of adverse outcomes will be ISAR scored within 4 hrs .
Std T1. All patients will be transferred to the most appropriate care setting following a decision of ‘medically fit for discharge’ as follows:
Standards to be developed
David Oliver model for frail elderly – shared via Kings Fund
Note – model may be extended for other groups: children, other people with long term conditions
Note: David has been a practising hospital doctor for 24 years and a consultant, specialising in geriatric and general internal medicine, for 15 years. He has been lead clinician and clinical director for both South London NHS Trust and the Royal Berkshire NHS Foundation Trust.
He was the government’s National Clinical Director for Older People’s Services at NHS England
Std H2. Primary care will respond to a request for a GP visit and make a ‘treat/refer/admit /no action’ decision within 4 hrs
Std A2. Patients with an ISAR score of 3 or more will be notified to the CGA case manager and assessed*within XX hrs
Std C2. All patients in crisis will start to receive a package of enhanced support at home within 2 hrs of the need being identified. NB working patterns
T1a. For first time care home placement: Arrival by within XX days of the decision
Std A3. All patients in hospital will be assessed* before they leave hospital. HOLD pending D2A discussions
T1b. For return to care home: Arrival by if decision by By next day if decision after 14.00
Std C3. Within XX hrs of the need being identified for a Community bed, all patients in crisis will be transferred to that bed
* All assessments are carried out using a Comprehensive Geriatric Assessment (CGA) approach
T1c. For assessment bed / I.C. bed: Arrival within 24 hrs between and 16.00

5. Pioneer Communities
Expression of interest: Health and Social Care Integration Pioneers
Builds on learning: brings in expertise
Data analysis
Modelling
Health economics
Contract design
Workforce advice
National political support
Norman Lamb MP
Health minister

6. What’s on offer?
Consideration of freedoms and flexibilities at national level
Support to address local barriers
Commitment to look at changes to national rules
Expertise, but no funding
Even if we don’t get chosen, the process of documenting our potential, commitment and aims for integrating care and support will help to galvanise the economy into a single, shared and collectively delivered vision.

7. Delivery Full delivery Agreed model Immediate local change
One extra patient, per practice, per week, cared for in an appropriate setting =
money released for lower cost, community based alternatives
Immediate local change
Agreed model
Full delivery
Five
years
Max two
years
October
2013
Building on work already in our programmes
We are doing many of the right things, we just need to coordinate our efforts
Freedom to test cash-releasing ideas