Wakefield District has been working with partners from health, social care, housing, and the voluntary sector since 2010 to co-design a care system that is capable of supporting the needs of local people. This is about developing integrated approaches to care targeted at the most vulnerable people, with a strong focus on self-care and proactive intervention.
In January 2015, the NHS invited individual organisations and partnerships to apply to become ‘vanguard’ sites to work with national partners to co-design and establish new care models, tackling national challenges in the process.
Wakefield District has been working with partners from health, social care, housing, and the voluntary sector since 2010 to co-design a care system that is capable of supporting the needs of local people. This is about developing integrated approaches to care targeted at the most vulnerable people, with a strong focus on self-care and proactive intervention to promote well-being for both children and adults. Connecting Care is the banner under which new models of integrated care is being developed and delivered within Wakefield
As part of this, there has been recognition in Wakefield that the quality, experience and level of care provision has not been equitable between those living in their own homes and those living in care settings. Wakefield has therefore introduced a specific focus on care homes within Connecting Care to address the high level of fragmentation in how care was delivered. Wakefield is aiming to improve the health and wellbeing outcomes for people living in care homes and assisted living facilities.
The multi-disciplinary team (MDT) makes a real difference to vulnerable patients in care homes by carrying out holistic assessments, developing personally tailored care plans, delivering pro-active care to residents and training to care home staff with the overall aim of improving resident’s experiences.
The holistic assessment is carried out using a range of ‘listening tools’ from AGE UK Wakefield District and South West Yorkshire Partnerships Foundation Trust including: LEAF-7 Designed to be used by support workers working with vulnerable people, typically in later life. It is simple to use, systematic and measures the things that people have reason to value; Pull up a chair Based on the ‘Pull up a chair’ campaign, the concept aims to gain insight and evidence on the experience of residents through, for example, video diaries; Dementia Care Mapping prepares staff to take the perspective of the person with dementia in assessing the quality of the care they provide. It empowers staff teams to engage in evidence-based critical reflection in order to improve the quality of care for people living with dementia; ‘Portrait of a life’ uses e-learning for care home staff and carers to use life story work to support well-being and resilience of people with dementia.
Portrait of a Life and the other holistic assessments have made a significant difference to the care that is provided in the homes, this has been recognised during a recent CQC inspection of one of the care homes where staff were praised for their person centred care and focus on individuals.
It has been acknowledged that care homes cannot provide everything that someone might need to enhance their health and wellbeing so links and relationships are being made with the local Community Anchors. By blurring the boundaries between care homes and the voluntary and community sector, greater opportunities are being identified for care home residents.
One example of this is where a resident identified that his health and wellbeing would be improved by spending some time gardening. This was one of the things that he had missed since moving into the care home. As the care home doesn’t have a garden, they contacted the local Community Anchor and arrangements have been made for the gentleman to work on their garden, with support from a volunteer for the first few weeks until he settles in.
In addition to making a real difference to residents, the Vanguard is also making a real difference to staff. The dietician that works within the Care Homes Support Team, through working with the MDT, has developed her skills and confidence to assess the residents holistically. In the past, she had generally concentrated on her own area of expertise however she now recognises where the residents will benefit from input from other members of the MDT and acknowledges the importance of the assessment tools in looking at the whole person.
Staff in the care homes have given feedback that they feel more confident, know where to go to ask for clinical support and believe that they have seen a difference to residents’ health and care since the Vanguard began.
GP Enhanced Service – Phase one of the Vanguard involved the development of a GP Enhanced Service, where one GP practice supports one care home. The practice is funded to support the home in the most appropriate way; this has led to the development of weekly home rounds for some of our care settings and has improved relationships between the practice and the care home. The residents and tenants, and their families, know when they will be seen and who by, and that if someone needs an appointment more urgently, this can be arranged. It is also a more efficient use of time for the practice staff and clinicians from practices.
Improved liaison – The Registered Mental Health Nurse (RMN) from the MDT is piloting a new way of working with the Consultant Psychiatrist; they will meet and discuss individuals in detail so that the consultant can make recommendations, the nurse then passes these recommendations on to the GP (who has overall prescribing responsibility) so that changes can be considered. This means that residents will no longer require a referral to the Community Mental Health team and, because they are not added to a waiting list, changes to their care can be implemented much quicker.
Improved care – The positive difference being made by the MDT can also be demonstrated with individual case studies. One of our care homes requested some support from the MDT because one of their residents, who has a diagnosis of dementia, was presenting with challenging behaviour. He had recently been hospitalised with pneumonia and his family were told that he did not have any rehabilitation potential.
The Matron and the RMN visited the home to meet this resident; they also assessed his care home notes, mental health records and spoke to his family and carers. It was established that his challenging behaviour came about because of how his personal cares were being managed so work has been done with carers to develop an understanding of this. The MDT therapists (speech and language therapist, physiotherapist and occupational therapist) will be going to re-assess this man so that his rehabilitation potential can be established and his wife can make an informed decision about whether he can return home.
Products and services – In addition to holistic assessment and enhanced support from primary care, the Vanguard has also developed and is developing a range of products that will continue to make a difference to residents, their families and carers and members of staff:
Wakefield Health and Social Care communities agreed that care must be organised around patients and citizens and that integrated delivery would be essential for success. The care homes vanguard project is at the heart of this as it is focused on improving the quality of care for some of the most vulnerable citizens in the district. The Wakefield Provider Alliance led the bid for the care homes vanguard and it is their staff that are delivering the holistic model of care.
The Provider Alliance has representation from statutory and non-statutory provider organisations who have come together to design a delivery model for future services and support.
The Provider Alliance includes representation from:
Wakefield District Council; Mid Yorkshire Hospitals NHS Trust; South and West Yorkshire Partnership Foundation Trust; Primary Care providers; Spectrum; Yorkshire Ambulance NHS Trust; Wakefield and District Housing; Carers Wakefield; NOVA; and Wakefield Assembly.
The Provider Alliance has laid out its aims as: Shared commitment to be ambitious in transformation; Thinking about communities and citizens rather than ‘patients’ or ‘service users’; Self-care and prevention; Integration across health, social care and third sector; Developing the workforce to meet the needs of the model; Innovation for technology and commissioning; Financial sustainability; and Whole system cultural change. All members of the provider alliance have now signed up to an alliance contract with joint outcomes measures for the care home vanguard project, demonstrating the commitment as a system.
Originally the Vanguard MDT included nurses (general and mental health), pharmacists and occupational therapists & a health care worker. A gap was identified in relation to the support available to carers of residents. This gap was discussed with the Provider Alliance and Carers Wakefield were approached to identify a solution. By changing the way their services are configured, they were able to offer co-ordinated sessions, working with the Vanguard MDT to deliver educational sessions, practical and emotional support to carers.
As Carers Wakefield have been working with carers and families they have identified the need to promote their services more in care homes and hope to get involved pre- admission to a care home to offer support at that time as well. These developments came about as a direct result of resident and carer feedback.
Continuous improvement is a core part of the Vanguard programme, and listening to staff and residents is a primary way of ensuring that services are fit for purpose. One element of the Vanguard offer is Pull up a Chair. This concept was developed by Age UK and aims to gain insight and evidence on the impact and experience of residents through, for example, video diaries. The care home managers and staff are asked for feedback regarding any areas that they particularly require support with and have informed the shape of our service improvement. Particularly in relation to training mapping and the development of a consistent, personalised care plan. Development of a ‘grab bag/ folder’ for hospital admission and discharge is another element of the vanguard that was identified as required though feedback from homes and the acute trust. It will be developed with input from our partners.
The holistic assessments work has engaged individuals to drive service improvement by providing activities that people have requested. The Community Anchors and volunteers are responding to what residents want. As well as listening to staff and residents, we have also involved wider patient groups in the development of the Vanguard offer. Our local Public Involvement and Patient Experience Committee have been consulted to ensure that their ideas are included in future work. Since the initial meeting PIPEC members have met with the MDT and project team to discuss in more detail the provisions for people in care homes who are deaf or hard of hearing and another member has offered to go and speak to staff to raise awareness of the needs of the trans-gender community in care homes.
One of the key lessons that we have learnt was regarding the staged roll out of the team. Practicalities in relation to the availability of staff meant that the team came together over a number of months. Given the tight timescales, as staff were available, they began their roles. This resulted in inconsistencies, a drawn out induction period, communication challenges and problems with evaluating the “before” and “after”.
In hindsight, there would have been better coordination of the availability of staff at the outset and a planned approach to two key start dates rather than a rolling programme of recruitment.
We have found that the smallest things have the greatest impact. We had anticipated that there might be challenges around co-location and information sharing, and around the availability of staff and around securing the right staff. What we hadn’t anticipated was the extent to which individual team members would have to step outside of their comfort zones.
The Vanguard is aiming to blur the lines between physical and mental health and make holistic care the norm. In order to deliver that ambition, the team have had to adopt a very flexible approach to their roles, focused on resident and carer needs rather than a defined job description. This has proven to be one of the greatest challenges. Where initially members of the team had expectations of their role being the same as it had always been, but in a different setting; because we want every contact to count, and we want there to be a focus on the whole person rather than their physical health and their mental wellbeing as separate entities, the team have had to develop new skills, learn new things and be willing to work in new ways.
We have been able to overcome this challenge due to the professionalism, commitment and drive of the individuals within the team. Each member of the MDT is committed to delivering improved outcomes for residents and that has given them a reason to overcome the challenge.
The vanguard project was established to develop a new model of care that was sustainable within the district. The two key elements of the project were to establish an enhanced service with general practices moving towards one practice to one care home and the establishment of a MDT that would link into existing community services. The enhanced service is made sustainable through the fully delegated co commissioning responsibility that the CCG has and the MDT role is to train and develop staff within the care homes and community so that the relationships and working practices are developed and become business as usual.
Robust evaluation is vital in order to be able to roll out any models of care in the future we need to understand how and why the current programmes work and what they are achieving. An iterative evaluation approach enables the programmes to develop in response to staff, resident / patient and carers’ feedback and learn from what the quantitative data and intelligence gathered tells us. This flexible approach maximises the chances of the programme’s success.
A controlled study, comparing care home implemented sites with normal care is underway. We are currently regularly interviewing forty staff as part of our wider integration evaluation. For the care home vanguard evaluation we are building on this good work and carrying out individual interviews with staff.
The evaluation measures the experience of residents in a quantitative way focusing on their experiences of integration and their self- reported wellbeing status. Wakefield District have a tried and tested way of gathering this data through their current patient involvement work delivered via Healthwatch Wakefield, which utilises trained volunteers to carry out one –to-one interviews.
The proposal for undertaking a robust evaluation of this model of care for care homes is to provide the care homes with the tools to record the information and ensure that appropriate agreements and training is in place to support this process of data collection. The evaluation initially monitors the ‘first phase’ homes and residents in 2015/16 against a control group of homes of a similar size and composition to measure the impact of the interventions against the key metrics identified.
To date the results against the control group are: Emergency admissions have reduced by 27% A&E attendances have reduced by 16% Ambulance call outs have reduced by 16%
In addition to data, the project team receive feedback from members of the MDT and care home staff on a regular basis. One care home manager recently wrote: ‘I’m seeing a big difference for the staff and residents… It is about nursing the person, not just their physical ailments.’ Joy Allen, Care Home Manager, Hemsworth Park
Learning is shared with the New Models of Care Team, NHS England in the form of case studies, reports and involvement in the ‘Learning Lab’ with the Independent Care Sector Programme. The ‘Care Homes Six’ also share learning with each other: fortnightly conference calls take place between us and the other five CCGs that have Care Homes Vanguards (with NHSE); site visits have been arranged to gain a better understanding of the detail of each model; ad hoc advice and guidance are given. We also discuss our work with other CCGs that contact us because they want to know more about elements of the model.
Learning will also be shared with other Wakefield care homes, independent living schemes and assisted living schemes that are not part of phase one of the vanguard.
The Wakefield Care Homes Vanguard project team have attended a number of conferences to disseminate learning, particularly regarding mental health integration and the work with community anchors. The care homes managers and staff are more connected as a result of the Vanguard work and participate in a monthly meeting to network, share learning and support each other. The Care Homes Forum is also an opportunity for the vanguard team to support the care homes staff and engage to inform future work. We have also set up a network for activities coordinators from the homes so that they will be less isolated in their roles.
Learning is shared with the New Models of Care Team, NHS England in the form of case studies, reports and involvement in the ‘Learning Lab’ with the Independent Care Sector Programme. The ‘Care Homes Six’ also share learning with each other: fortnightly conference calls take place between us and the other five CCGs that have Care Homes Vanguards (with NHSE); site visits have been arranged to gain a better understanding of the detail of each model; ad hoc advice and guidance are given. We also discuss our work with other CCGs that contact us because they want to know more about elements of the model.
Learning will also be shared with other Wakefield care homes, independent living schemes and assisted living schemes that are not part of phase one of the vanguard. The Wakefield Care Homes Vanguard project team have attended a number of conferences to disseminate learning, particularly regarding mental health integration and the work with community anchors. We have also hosted visits from Ian Dodge, NHS England and NHS Confederation.
The care homes managers and staff are more connected as a result of the Vanguard work and participate in a monthly meeting to network, share learning and support each other. The Care Homes Forum is also an opportunity for the vanguard team to support the care homes staff and engage to inform future work. We have also set up a network for activities coordinators from the homes so that they will be less isolated in their roles.
As a society we are increasingly aware of the impact that someone’s mental health and wellbeing has on their entire life, and of the lives of those around them. However, the stigma of having a mental health problem continues, and people still don’t truly understand the reality of living with dementia, depression or anxiety.
To look beyond someone’s challenging behaviour and truly understand the fear and anxiety that that individual might be feeling, and be able to respond to that in a positive, enabling and compassionate manner requires knowledge, skills and experience.
By breaking down barriers, educating professionals, supporting families and carers and embedding holistic assessment and care as the norm; the Vanguard MDT has had an overwhelmingly positive impact on the Care Homes’ ability to respond to the needs of their residents. This is the learning that we aim to roll out, and what we think sets our Vanguard apart from the rest.
