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Care in the Community

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paul Strickland

on 16 October 2015

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Transcript of Care in the Community

Care in the Community

Dr Lesley Bowker
Dr Paul Strickland
WHO is involved ?

1) General Practice
(The Primary health Care Team)

2) CCG- The Commisioners

3) Norfolk Community Heath and Care (Community NHS TRUST)

-district nurse -Admission Avoidance Team
-physio and OT -Care at Home team
- HCA
-Community Matron - Integrated Care manager - Case Manager

4) Norfolk and Suffolk NHS Foundation Trust (aka Mental Health)

- link worker/ CPN
- IAPTS
- TADS

5) SOCIAL SERVICES

- Social worker
- Carer (subcontracted)
- OTs (more)
- Housing- Housing Associations

6) Charities/Volunteers

Help the aged, Macmillan, Marie Currie,Dementia Support

7) HOSPITAL

Liaison nurses-dementia
Outreach nurses-COPD
Community MFE cons
End of life care teams
Domiciliary visits
Who is doing what?
Who is in charge?
Who's paying ?
80 years old
PMH- OA both knees
- Moderate dementia
Medication
- "butrans" patch 5ug/hr
- paracetamol 1g qds
Mr Smith
Social History
Widower
Retired School Cleaner
Enjoys his garden
Nearest relative- Niece in Southampton
No formal social help
Neighbour "pops in" (young at 72)
House is cold. Coke fired back boiler
Cat


Presenting Complaint c/o
Fall- found in the garden by neighbour 1800
Friday night
Tel. GP-answerphone, then 111,
Too busy - tel 999
Paramedic notes- "muddled"
- Can't stand
- cold extremeties
Admitted NNUH at 1900hr

10% admissions have adverse patient event
Half of these potentially fatal
5000 drug related deaths in UK hospital p.y.
30% events are preventable

90% all pt contact are in primary care 2%
2% risk
Is This a good place for Mr Smith to be?
Question 1

How could Mr Smith's
admission have been
prevented ??
Physical
- Falls prevention aids
- piper alarm
- better pain control
- fewer medication s/e

Psychological
- dementia care package
- anti-cholinesterase inhibitors

Social
- care package
- "alternative" housing
Clarked by junior doc. at 1930 hrs

-no history
-niece uncontactable
-AMTS 3/10
- temp 34.0 C
Cannula
Bloods
CXR
ECG
Home- garden- Ambulance- A+E- MAU- Bed on ward
? 1800 1830 1930 2100 2300
Contact- relative/ carer/SW/GP for Hx and d/c

Working diagnosis- act on it doctor!

Personalised "good" nursing

Physio and OT assess functional priorities
-ADL, mobility,
- steps, heating, heating, lavatory



ALL OK; MEDICALLY FIT FOR DISHCARGE
BUT;
MFE team priorities

Neice not happy-Phones social worker
"he wont be able to cope"

Needs a care package which includes
- new heating system (!!)
- NO LOCAL CARERS AVAILABLE


Delayed discharge
- deteriorating cognition

- reduced functioning

- increased dependence

- ££££££££££££££££££££
Question 3)

What are the options?

Are there alternatives to keeping Mr Smith
in the NNUH?
"I was alright before. Why cant I go home?"
Home - but does Mr Smith have capacity?

Planning bed

Intermediate care

Permanent Nursing Home

Sheltered housing

Respite care


Community Care
1) Care package- get up and tuck up *2
2) ICM insures OT/ Physio assessment
2) Niece pays for heating improvements
3) CPN for elderly visits regularly for dementia care monitoring
4) Regular reviews at home by GP/NP/Community Matron inc medication
5) Maintained on ICM list
6) Mr Smith gets AA and uses this to pay for neighbour to do his shopping

Acute on
CHRONIC

DELIRIUM
DEMENTIA
Mechanical

- steps
- doors
- shingle
- rugs
- slopes
Equilibrium

- senesecence
- dementia
- drugs
- alcohol
- joints
- anxiety
Question 2

What is Mr Smith's priority?
Question 3

What is the Medical Team's priority?
WHERE IS IT HAPPENING

Patient's home

Relative' home

Residential homes

Nursing homes

Sheltered housing

Intermediate care facility

Rehabilitation
Question 0)
What do GP teams do?
Accute illness - life threatening or not

Listening and Advocacy

Continuity and Co-Ordination of care

Chronic illness - detection and management
- reduce sufferring
- reduce complications
- End of Life Care

Multiple complex disease

Increased Activity

Healthier population living longer

Brittle Morbidity
HOW DO WE FIX THE DILEMA?

Multiple Agencies

Fluctuating situation with time

Different funding streams

Winter pressures- poor decisions


Question 4

What would
you do?

INTEGRATED CASE MANAGEMENT
(ICM)

-Single Point referral and contact

-Linked social and health care (unique)

-Common MDT with patient at centre

- Maintaining "Lists"

- Common annotation through Systemone

IT IS POSSIBLE TO DO THIS WELL
Question 5
What difficulties prevent this being done well?

- Spiraling demand

- Poor pay for carers/ Poor recognition

- Unpredictable peaks in demand (flu)

- NHS morale

- Recruitment crisis

- Other national priorities

-Societal norms - who is responsible

If you had 1000 days left to live how many would you chose to spend in hospital?

48% of people over 85 die within one year of hospital admission
Imminence of death among hospital inpatients: Prevalent cohort study
David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med






10 days in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80
Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity, and social activity.
Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63:1076–1081.


If you had 1000 days left to live how many would you chose to spend in hospital?

48% of people over 85 die within one year of hospital admission
Imminence of death among hospital inpatients: Prevalent cohort study
David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med






10 days in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80
Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity, and social activity.
Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63:1076–1081.


If you had 1000 days left to live how many would you chose to spend in hospital?
48%

of people over 85 die within one year of hospital admission

Imminence of death among hospital inpatients: Prevalent cohort study

David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med

10 days in hospital (acute or community) leads to the equivalent of
10 years ageing
in the muscles of people over 80

Questions???
Full transcript