Marc Hopkinson

Gateshead Care Home Programme

Our Mission & VisionMission: Working together to improve the health of Gateshead

Vision:Care for people in a seamless wayEnsure commissioning is clinically led and driven by

patients and carer involvement Improve the quality of health services

Quality of Care

Working together

CompassionImproving

LivesRespect &

DignityEveryone Counts

Needs increasing: scale

Now• 191,000 population• 18% over 65 years • 3.7% over 85 years• 0.85% living in care

homes• Median length of stay 20

months (23 in Nursing, 27 in Residential)

2030• 203,000 population• Aged 65 + increase of 1/3

(34,000 – 45,000) • Over 85 years - 90% increase

(3,900 to 7,500)

Quality not right nowFrailty is the issue

• Care is reactive … we need specialist proactive• Variation e.g. multiple practices causes problems• Communication issues across settings -

admission/discharge • Care planning inc advanced care (In and OOH)

Older People (40, 000 aged 65 +)

Residential Care Homes17 homes (596 patients)

Nursing Homes15 homes (907 patients)

Specialist Care Homes(including Learning Disability, Promoting

Independence Centres and Specialist Mental Health)

Older People supported to live at home aged 65+ (4273 patients)

Aim:

To improve the care of patients and familiesthrough more integrated proactive care

Objectives:

Improve each care setting and bring them into a ‘frailty team’• Increasing skills and understanding in homes.• Changing reactive primary care delivery to a

proactive model involving weekly visits by a lead GP from the care homes linked practice

• Comprehensive care planning and MDT case management led by specialist nurses at the weekly ward rounds with ongoing support to homes

Objectives (Cont)

• Bringing specialists into a virtual team to support when needed and improving communication between

• Reduce avoidable hospital admissions• To be cost saving

Pilot Results

• Investment of approx £50k• 98 patients case managed• 45.5% reduction in admission rates

based on 2008/09 data- admission days 440

- admission costs £243,146

• Savings assuming same conditions/reasons for admission for total care home population in Gateshead:

- 6763 bed days - £3,730,446

• ‘You gave me my father back’

Care home staff

Specialist input (OAP, SALT, Physio)

Outpatient geriatrician

Inpatient

Lead GP, Specialist Nurse

Patients, Carers and families

Expanding this across Gateshead

• Care homes trained• 28/34 Care homes linked to practices• 6 specialist nurses proving comprehensive

reviews, care planning, liaising and reactive care

• Medicines Management Team• GHFT Geriatrician • Laptops• Key partners- LA, OA Psychiatry

Specialist Nurses

Commissioned

The Project Group

• Dr Mark Dornan• Lesley Bainbridge• Lynne Shaw• Dr Daniel Cowie• Dr Louise Crabtree• Marc Hopkinson

Any Questions?

http://gatesheadccg.nhs.uk/about-us/case-studies/