Health and social care organisations in Derbyshire have been working closely together for some time, to improve care and services for people and make them as efficient and effective as possible.
A housebound patient is someone unable to leave their home due to physical or mental illness. It includes people living in their own home or a care home. These patients tend to have complex health and social care needs. Being housebound can be a permanent or temporary situation.
This team will provide anticipatory (also known as ‘proactive’), planned and urgent care. If someone is housebound and needs a service, this team will deliver it. This team is not a new or ‘add on’ service – it is a teaming up of existing services – with general practice, community, mental healthcare, adult social care and the voluntary and community sector all working together.
The overall aim is to keep people safe at home and provide the best, most seamless, care, keeping people out of hospital wherever possible. Team Up Derbyshire aims to ensure that person-centred care services are provided at the right time, in the right place, by the right person. As a result, people should be able to live well, for longer.
Team Up Derbyshire (including Ageing Well) is being advanced locally by the primary care networks across Derby and Derbyshire – with the support of local place alliances and all health and care organisations.
People in England can now expect to live for longer than ever before – but these extra years of life are not always spent in good health, with many people developing conditions that reduce their independence and quality of life. The health and care sector has a key role to play in helping older people manage these long-term conditions, making sure they receive the right kind of support to help them live as well as possible. The NHS Long Term Plan (January 2019) set out a vision to give people greater control over the care they receive, with more care and support being offered in or close to people’s homes, rather than in hospital.
The national Ageing Well programme is a requirement of the NHS Long Term Plan and concerns how the population is looked after in the community (outside of hospital). There is no age criteria although the vast majority of community resources are used to care for and support the moderate and severely frail population, of which there are approximately 30,000 in Derbyshire. The moderately and severely frail population in Derbyshire had 96,605 hospital bed days (in 2019-20) – the equivalent of about 10 wards. This figure is only predicted to increase in the future.
Team Up Derbyshire’s objectives are to:
Team Up Derbyshire includes a new approach to providing a home visiting service for patients, helping prevent emergency department admissions, and relieving GP workload. It brings together step-up support (when an individual needs additional support to help avoid a hospital admission) and discharge pathways (ensuring that there are suitable options in place to allow people to leave hospital when appropriate to do so).
Team Up Derbyshire also incorporates three key initiatives of the national Ageing Well programme. These are: community urgent response (reducing the need for hospital admissions), enhancing health in care homes (providing comprehensive support to care homes and their residents), and anticipatory care (working proactively with patients to maintain or improve health and wellbeing, and thereby reducing the need for hospital care).
An acute home visiting service is a responsive and effective home visiting service for patients that prevents them attending emergency departments and relieves GP workload. The service provides timely assessment and support for vulnerable patients. As well as being designed to help prevent hospital admissions, the acute home visiting service should improve patient experience and lead to a better use of resources.
Housebound patients (in residential care or their own homes) are at higher risk of deteriorating health and hospital admissions. For GPs, home visits have to be fitted in around other surgery commitments, and smaller GP practices, in particular, can struggle to meet on-the-day peaks in demand for home visits. This has previously meant that patients unable to attend their surgery could experience a delayed holistic assessment of their needs.
Responsibility for providing the service will be across a larger footprint than a single GP practice. New approaches are now being explored in areas such as Erewash, Derby and Chesterfield. In the city and county, the aim is to provide an acute home visiting service which makes better use of the workforce, with visits being provided by a range of different professionals according to patient need. This will increasingly see nurses, therapists, paramedics or social care practitioners carry out home visits. While GPs will still visit people at home under this approach, their role will increasingly be one of overseeing patient care, supporting other members of the team. In this way, a range of professionals will provide the care that is most appropriate, working together as a team.
The urgent community response service aims to support people with complex needs to live safely in their communities, through co-ordinated and responsive care, avoiding unnecessary admission to hospital and long-term care
The urgent community response service is set to provide crisis response care within two hours of referral and reablement care within two days of referral.
A crisis response service is a community-based service, typically provided by a multi-skilled team to people in their home with an urgent care need. Reablement care is a community-based service, typically provided by a multi-skilled team to maximise independence, and involves an assessment and intervention(s) to achieve goals set with the person. This is the active process of an individual regaining the skills, confidence and independence to enable them to do things for themselves, rather than having things done for them.
The current response to people in their own home who have an urgent need is largely via the ambulance service or general practice. This approach is flawed because it is delivered by a single clinician who can feel time-pressured and unsupported or that they are alone in problem solving. This can also result in reliance on hospitals as a place of safety rather than reserving them for specialist provision of healthcare. It is proposed to develop community multi-disciplinary teams to be the default first line urgent community response. This will see a response not only to the presenting issue and the need to ‘make safe’ but also with an explicit remit to identify and address underlying issues.
People living in care homes should expect the same level of support as if they were living in their own home. This can only be achieved through collaborative working between health, social care, the voluntary and community sector and care home partners.
The NHS Long Term Plan contained a commitment, as part of Ageing Well, to roll out enhanced health in care homes across England by 2024. This reflects an ambition to strengthen support for the people who live and work in and around care homes, including how urgent community response is accessible to people living in a care home.
Enhanced health in care homes should see GP practices aligned to care homes, the development of multi-disciplinary, weekly home rounds to care homes and personalised health and care plans put in place for residents. For the purposes of this programme, a care home is defined as a Care Quality Commission-registered care home service, with or without nursing.
There are seven components of the care homes framework:
Older people living with frailty are the highest users of services across health and social care and have the highest levels of emergency admissions to hospital. Yet with greater use of anticipatory care (also known as proactive care), we can identify patients at risk of hospital admission in future, and support them before things go wrong. Anticipatory care will help people to live well and independently for longer through proactive care for those at high risk of worsening health outcomes. For anticipatory care to succeed, we need to understand the housebound population better and use those insights to provide more personalised approaches.
Anticipatory care would be provided by teams of professionals such as community matrons, nurses, physiotherapists, occupational therapists, pharmacists and social workers working together, ensuring the right support at the right time. The programme is at an early stage in Derbyshire, with initial discussions and plans being progressed.
Step up care describes a pathway for people who are tipping into or have tipped into a care crisis and who have a care need that cannot be managed within their own home or they cannot be left safely at home. At this time they may benefit from being stepped up into care such as a community reablement bed or a care home bed.
It is commonly recognised that many patients end up in hospital because they are not able to access the appropriate wrapround support in the community. This part of the programme will enable multi-disciplinary teams, involving professionals such as nurses and therapists, to quickly provide more support, often temporarily, to prevent hospital admissions.
This programme mirrors ‘step up’ but sees services put in place in the community to receive patients from hospital. Patients who are clinically able and do not require an acute hospital bed, but may still require care services, are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting.
In Derby and Derbyshire, there are three discharge to assess pathways with pathway one being a transfer to home for further assessment to determine a person’s ongoing care needs. As well as an assessment in the home, there may be a period of rehabilitation provided by the community health and social care teams.
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