Background and summary of local evaluation

In March 2015 Wakefield CCG, in partnership with local health and social care providers, formed an Enhanced Health in Care Homes (EHCH) vanguard. This was one of the new care models that was announced in the Five year forward view for the NHS in England.

The aim of NHS England’s EHCH vanguard model was ‘[…] to ensure the provision of high-quality care within care homes […] to ensure that, wherever possible, individuals who require support to live independently have access to the right care and the right health services in the place of their choosing and to ensure that we make the best use of resources […] whilst ensuring the best care for residents’.

The CCG states that the aim was ‘to ensure that local people receive person-centred coordinated care, which is delivered at the right time, in the right place and by the right person.

The first phase of the vanguard covered 15 nursing and residential homes with a total of 999 beds. Eleven care homes started receiving the enhanced support in February 2016 and an additional four in September 2016. There were also two supported living schemes that received some parts of the enhanced support. The second phase of the vanguard started in April 2017 when 12 more care homes and four supported living schemes joined. This evaluation focuses on the 15 care homes in the first phase of the vanguard (referred to as vanguard care homes in this report).

There was a separate new care models vanguard – a multispecialty community provider (MCP) – in West Wakefield established at the same time as the EHCH (March 2015). The MCP aimed to move specialist care out of hospital and into the community but there was no focus on older people in care homes.

In April 2017, at the start of the second phase of the care home vanguard, the care home vanguard merged with Wakefield’s MCP vanguard to become part of the Connecting Care programme.

What changes were introduced in vanguard care homes?

The Wakefield care home vanguard identified six overarching areas within their Care Home Outcomes Framework that they were hoping to impact:

• Care is co-ordinated and seamless.

• Urgent care should only be provided to those who require it.

• Improve management of long-term conditions and falls.

• Improve management of end-of-life care.

• Increase proactive case management and personalised care planning.

• All staff understand the system and work in it effectively.’

The quantitative elements measured within the urgent care area included ambulance call outs, emergency bed days, A&E attendances and emergency admissions.

A timeline of some milestones can be found in Figure 1.

Figure 1. Timeline

Source: analysis by the Improvement Analytics Unit

Each strand of the care home vanguard is described in detail below.

Voluntary sector

Voluntary organisations set up social activities to get residents out and about, such as health walks and tea dances. Other activities took place inside care homes, for example visits from a therapy dog and a choir. Age UK’s Pull Up A Chair programme filmed interviews with residents, giving them a chance to talk about their life. Where this revealed a need for extra help, the older person would be signposted to relevant support services. The Portrait of a Life toolkit encouraged residents to talk about their life story as a way of helping care home staff tailor their support to that person’s life experiences. Carers Wakefield was also involved, providing information, advice and support and liaising with other services when necessary.

Multidisciplinary team

A new multidisciplinary team (MDT) that would be proactive in planning and managing care for the vanguard residents was set up. The team used a screening process to identify care needs which, if not met, could lead to residents needing inappropriate hospital care. The team (comprising professionals from areas including mental health, physiotherapy and nursing) was co-located and met weekly to discuss case management and would proactively see residents that needed more support. The MDT also carried out falls risk assessments at care homes and delivered 49 training sessions covering 286 care home staff. The training covered falls prevention, falls management, screening for malnutrition and swallowing problems, dementia awareness, and pressure sore prevention. Initially, the MDT planned to screen all vanguard residents for unmet needs, but from April 2016 this was narrowed down to screening only those residents deemed high risk by care home staff. There was no common definition of high risk used by all care homes and in some care homes almost all residents were referred to the MDT whereas in others only a few were referred. If extra care needs were identified, the MDT could refer to other members of the MDT, for example a physiotherapist or other services in the community. According to estimates from Wakefield CCG, around 400 residents were referred to the MDT between November 2015 and April 2017.

Primary care

Twenty-six out of roughly 40 GP practices were selected to participate in the vanguard, based on having at least one patient living in a vanguard care home.

All GPs in Wakefield, not just the ones affiliated with the vanguard, already visited their care home patients when required even before the vanguard started and continued to do so. The frequency of visits differed between practices and was largely based on the practice’s relationship with the care home and the vanguard. The vanguard set out to implement a ‘one GP practice one care home’ model, which was not achieved during the period of the study.

Local key performance indicators (KPIs) were introduced in November 2015 specifically for the GPs in the vanguard. The new KPIs included, for example, face-to-face consultation within 14 days of registering a new care home resident, a full health care plan within eight weeks of registering and emergency admission reviews within seven days of a discharge letter being received. Additional payments for the care outlined in the local KPIs only related to residents in the 15 vanguard care homes. However, most of these local KPIs were already part of the standard contract for all GPs.

This means that any benefit derived from care delivered by GPs for residents living in vanguard care homes compared to those living in non-vanguard care homes in Wakefield was unlikely to be substantially different.

What impact were these changes expected to have?

The enhanced care package was expected to improve coordination of care through closer working between care home staff, GPs and the MDT. Access to the MDT and greater engagement from GPs was expected to reduce unnecessary emergency admissions and speed up the discharge process for residents admitted to hospital (thereby reducing the number of hospital bed days). The MDT was expected to improve case management and personalised care planning, and make sure that all residents had an end-of-life care plan that included their preferred place of dying. Training for care home staff aimed to reduce accidents and deterioration of residents’ health that might result in hospital attendance or admissions. The voluntary sector activities were expected to reduce the isolation experienced by older people but not necessarily have a strong impact on hospital use.

* Partners include the Mid Yorkshire Hospitals NHS trust, South West Yorkshire Partnership NHS Foundation Trust, Yorkshire Ambulance Service NHS Trust, Wakefield Council, Wakefield District and Housing, Age UK Wakefield District, Nova and Carers Wakefield and District.

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