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Integrated

care for older

people

Dr Elizabeth Kendrick National Professional Adviser for Older People 31 October 2016

About CQC: our purpose

The Care Quality

Commission is the

independent regulator of

health and adult social care

in England.

We make sure health and social

care services provide people

with safe, effective,

compassionate, high-quality

care and we encourage care

services to improve.

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About CQC: our role

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• We register health and adult social care

providers

• We monitor and inspect services to see

whether they are safe, effective, caring,

responsive and well-led, and we publish

what we find, including quality ratings

• We use our legal powers to take action

where we identify poor care

• We speak independently, publishing

regional and national views of the major

quality issues in health and social care,

and encouraging improvement by

highlighting good practice

About CQC: our role

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Register

Monitor,

inspect

and rate

Enforce Independent

voice

We register

those who

apply to CQC

to provide

health and

adult social

care services

We monitor

services, carry

out expert

inspections,

and judge each

service, usually

to give an

overall rating,

and conduct

thematic

reviews

Where we find

poor care, we

ask providers

to improve and

can enforce

this if

necessary

We provide an

independent

voice on

the state of

health and adult

social care

in England on

issues that

matter to the

public,

providers and

stakeholders

Building bridges, breaking barriers: integrating care for older people

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• Main purpose:

• review integrated care in our fieldwork sites and outcomes from these initiatives

• identify barriers to integrated care for older people

• describe examples of good practice in integrated care for older people and describe them in a way from which others can learn

• develop recommendations to improve care for older people

• Report focus:

• understand the differences in experience of older people and how these can be addressed and comment on the role of commissioning

• seek how to improve care as experienced by individuals and their families/ carers

• provide clear recommendations with ownership from relevant stakeholders, including CQC

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Purpose and principles

What did we look at?

In collecting evidence we focused on four key lines of enquiry (KLOEs):

1. Identification and prevention

How are older people with complex needs and/or high risk of deterioration in their health or social situation identified?

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2. Person centred assessment and planning

Do older people always have a person centred, holistic assessment which forms the basis of a plan of care which meets their physical, emotional, spiritual, social and practical needs, and is the plan regularly reviewed and updated?

What did we look at?

3. Co-ordination

Is care co-ordinated effectively to ensure that the older person is at the centre of their care, including when they have multiple or complex needs or vulnerabilities?

4. Recognition and management of change and wellbeing

Do services and professionals recognise and manage changes of an older person’s health?

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What did we do?

• Literature review on integrated care for older people

• Data review – analysis of CCG and LA level data on integrated care for older people

• A national analysis of quantitative measures of ICOP

• Undertook a CCG and LA information request

• Fieldwork in two pilot and eight fieldwork sites

• Care home interviews from local area fieldwork areas

• Involvement work, plus focus groups with hard to reach community groups

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What people told us

“[Telling the same story again and again] becomes draining and you end up just wanting to get out asap. How can a professional come to an appointment without some information?”

“I have had lots of falls/fractures and no follow up. I only get treatment for the fracture. There may be other issues for me as I was weak and there was no plan in place to help this.”

“My health is getting worse and also I cannot get to the surgery easily. GPs need more time to listen to understand how they can help me.”

“I hurt my arm when I had my fall. Physiotherapy were referred however they took 3 months to arrive and I was on the emergency list.”

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What people told us: care plans

Mrs P does not think that Mr P has a care plan. She has not seen one. She says “nobody is keeping an eye on him or me… its always been just us two, we soldier on.”

“Professionals should sit around a table to discuss a patient’s care plan and have a key document that is available to everyone. This is about health talking to social care but also about health talking to health.” (Service user)

“I’ve recently been sent a care plan from my GP; however I find it is not simple to understand and not very informative. I would rather have my own input into my own care plan and flag my vulnerabilities such as my asthma, my broken hip, my gallstones, my achy shoulder, my allergies to penicillin rather than having something that somebody cannot understand if they find me in an emergency”

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What people told us: coordination

“I didn’t even know he was going to be going home so I hadn’t brought his clothes with him to go home in.”

“When I have been in hospital for an appointment the consultant always says we will write to your GP and he will explain – why can’t they tell me right there?”

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“I have a lot of health problems and everything has been explained to me but, how do I know that the health professionals communicate with each other about my health problems?”

What people told us: recognition of change and management of wellbeing

“People fall off the radar once they have progressive disease. At the start (diagnosis) there is a flurry of activity, then this drops off. If someone has managed and not shouted for more help and support, care then appears to stop. It would be better to have an expectation that a need for care is recognised and in place.”

“I'd like to be offered a wheelchair which would help me to enjoy social outings with my residents at the sheltered housing accommodation. I feel quite isolated and I’m unable to join in with the activities.”

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Examples of good practice

• Bristol has a joined up IT system called Connecting Care, a viewing platform for health and social care professionals to view key data on diagnosis, medication, allergies, recent appointments and key individuals involved in the person’s care

• Some care homes had ‘resident of the day’ where a resident’s care plan is reviewed and updated and their wishes discussed with them and their families

• Weekly ward rounds by GPs into care homes to improve communication and integration

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Examples of good practice

• Joined up information governance across a Health and Well Being Board area, e.g. Hammersmith and Fulham, Wakefield, Portsmouth, to overcome confidentiality misconceptions

• Weekly borough-wide multi–disciplinary team meeting in Camden - reduced A&E attendances by a third and praised by all professionals we spoke to

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• Some areas, including Cambridgeshire and Bristol, have high level outcome measures set at an area level

• Stockton on Tees Frailty Service is streamlining how elderly care is delivered

Key findings

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• Services struggle to identify older people at risk of deterioration or unplanned admissions to hospital – no consistent approach

• Good examples of joined up working but not consistent

• Evaluation of initiatives was often lacking

• Lots of commitment to join up services but poor understanding of integrated care delivery

• Older people not routinely involved in decision making

• Older people, and those important to them, take responsibility for navigating complex local services – they fall through the gaps, have multiple care plans and are not involved in decisions

Building bridges, breaking barriers: CQC recommends

1) Locally, health and social care leaders build on the opportunities offered by initiatives such as the Five Year Forward View vanguards and Sustainability and Transformation Plans, to develop and agree a shared understanding and definition of integrated care for their population in their local area, and then work towards delivering this shared aim

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Building bridges, breaking barriers: CQC recommends

2) An agreed methodology is developed at a national and local level across health and social care for identifying people at risk of admission to secondary care or deterioration

3) Older people are meaningfully involved in making informed decisions about their care needs and care planning – in particular about the outcomes that are important to them – based on the existing national and local guidance

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Recommendations

4) Commissioners and providers ensure information and support is available and that this sets out details of available services, connections between different services, and how peoples’ accessibility requirements will be met.

5) A set of validated data metrics and outcomes measures for integrated care are developed and shared, with person-centred outcomes at the heart of decisions about service provision and being based on a consistent, shared view and definition of integration

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Why a new strategy?

Adapt and improve

We want to become more efficient and effective to stay relevant and sustainable for the future

The public, and organisations that deliver care, have told us we have improved but we know there is more to do

A changing environment

Use and delivery of regulated services is changing

CQC must deliver its purpose with fewer resources

Our new strategy

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Our ambition for the next five years:

A more targeted, responsive and collaborative approach to

regulation, so more people get high-quality care

1. Encourage improvement, innovation and sustainability in care

2. Deliver an intelligence-driven approach to regulation

3. Promote a single shared view of quality

4. Improve our efficiency and effectiveness

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Four priorities to achieve our strategic ambition

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Our independent voice: reviews of care

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More to come…. • Integrated urgent care

• How NHS trusts

investigate deaths

Reviews of care 2015/16

http://www.cqc.org.uk

/content/state-of-care

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Thank you

www.cqc.org.uk

enquiries@cqc.org.uk

@CareQualityComm

Elizabeth Kendrick

National Professional Adviser for Older People

elizabeth.kendrick@cqc.org.uk

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