Five clinical directors joined Pulse PCN editor Victoria Vaughan on Microsoft Teams to discuss how the Enhanced care in care homes service is working in their regions
Dr Katharine Bhatt, care home lead covering Baywide, Paignton and Brixham and Torbay PCNs – 2,100 care home beds
Dr Geetha Chandrasekaran, clincal director (CD) Halifax PCN, West Yorkshire – 240 care home beds
Dr Rajiv Mansingh, CD North Easington PCN, Durham – 400 care home beds
Dr Brigid Joughin, CD Outer West Newcastle PCN – 240 care home beds
Dr Paul Bowen, CD Middlewood PCN, Cheshire – 600 care home beds
In practice
Victoria: Katharine, as you’re responsible for the largest care home population, how has the implementation of the Enhanced care in care homes (EHCH) DES proceeded in Torbay?
Katharine We had an existing care home service prior to the EHCH DES, which was more focused on acute and proactive care in a handful of our care homes with the highest use of healthcare. We have adapted and enhanced that to deliver the DES, but one challenge is to not take away from the existing pathways that worked very well, while also delivering on the DES because it’s not the same work stream. [We are] trying to deliver that using the additional roles reimbursement scheme (ARRS) and a whole multidisciplinary team (MDT) approach.
In Torbay, where we had an established care home team that was already running well, and the practices knew what we did and what value we added, we see a reduction in acute visit requests to practices, acute admissions to the hospital and contacts to out-of-hours services, for example. There was more buy-in from an earlier stage than we might have had otherwise. I can see in the South Devon area, where the PCNs haven’t historically had a dedicated enhanced care home delivery service, it’s been quite hard to get people on board.
We had already started doing an MDT meeting on a weekly basis. We found that the community teams, the dietitians, mental health, speech and language services, were really keen, because they struggled to access timely GP advice when they needed it.
And this was seen as a real enabler. Rather than waiting for the [GP to] call back or send an email and hoping to get something in a couple of weeks’ time, we can make relatively nimble decisions that allowed us to progress the care for that patient. It’s been a real strength of implementation that’s persisted.
Victoria: How is everyone managing the challenge of not losing what existed before the DES came in?
Geetha What we had before from the CCG was a ‘Quest for Quality in Care Homes’ programme, and that was set up quite a few years ago as a proactive service, probably similar to what the enhanced care home DES says. We’ve adapted it a little in line with the enhanced care home DES, and we’re still trying to find how they both fit together. With Quest we soon found, because of the GP and practice workload, it turned into an acute service, so that the care homes started calling them for all the acute stuff, which they were okay with, and we do it as a Calderdale-wide project, which covers five PCNs.
So we’ve kept the care home DES arm, but we’ve also kept our acute arm. As part of that acute arm, there is already an MDT which includes a geriatrician, a pharmacist, a dietitian, and anybody else who is relevant. The Quest team is mainly led by quite senior community matrons and nursing staff, so they are well versed and experienced in what they’re doing, but we then had to incorporate it with the care home DES requirements. So, we used our care co-ordinators and our clinical pharmacist teams from the ARRS because they are funded and that was the purpose of bringing more workforce in.
Rajiv We had a vulnerable adult wraparound service (VAWAS), which the CCG set up about eight years ago. It’s a well-structured team working in all the care homes and the GPs are consulted for help when it’s needed.
When this [DES] came, it was building on what already existed. We found that compared to before, the care home managers and staff felt more empowered and also more involved with the MDT and all that, so that’s made a big difference. We were able to educate them to a higher level. There is a clinician who works very closely with the nurse practitioners who are working in the nursing home, and there’s monthly training going on, and the aligned GP works with them in educating. So it all diffuses through to the care home manager and the care home nurses and healthcare assistants. Holistically the patients are getting better care.
Brigid We used to have a care home project in Newcastle for nursing homes, but it was voluntary and not all of them took part. That has now been merged with the new DES. We’re struggling to work out where our specialist care home nursing team fits in with it all.
We’re having a lot of discussions about acute versus planned care, because our specialist nursing team was very involved at peak Covid, going into homes when people were unwell, and managing the likely Covid symptoms, and sadly also managing a lot of deaths. Because they were all drawn into that, we had nothing extra for the DES. Now as the Covid crisis in care homes has lessened, they have carried on running an acute service, and most of the PCN leads would rather they put their specialist knowledge into doing more of the planning, and also into looking after the complex elderly patients which is where their skills lie.
I think a lot of the value of teams is that they are consistent. Your nurse knows those residents. When they’re unwell they say ‘This is Dolly, she’s like this when she has a urine infection’. If you’ve got an acute service run by seven nurses who take it in turns, they don’t know Dolly.
Katharine Fundamentally we’re trying to fulfill quite a rigid black-and-white DES. But actually this is about establishing values, ethos and culture. The culture is that these are generally patients who are best cared for in a community setting, not an acute hospital. We need to encourage and nurture our clinical teams to be comfortable that they can do that, knowing that we have systems and processes to support a patient to safely remain in the community. We must enable our care homes to feel confident in holding that [risk], to then not put the phone down [after talking] to us and ring 999 because they’re [still worried].
Victoria: What do you think about the requirements of the DES?
Paul The DES goes into a huge amount of detail about what we should do, but it doesn’t cover the ‘why’, which our original enhanced service pre-DES did. Why is it important for this population to receive this type of care? What is the focus?
We established an enhanced care in care homes service across east Cheshire back in 2010, which we’ve obviously adapted with the publication of the PCN contract as well. Our initial approach was all about outcomes. It was: ‘You get on with it, practices; you do what you think is best for these individuals to achieve these outcomes.’ The outcomes that we mutually agree on are: people should live a full, dignified, comfortable life in the care home; they should avoid unnecessary hospital admission; they should avoid unnecessary attendance from an ambulance, unnecessary lengthy hospital stays and unnecessary falls. The CCG pre-DES judged us on these mutually agreed outcomes, not on whether we have a care plan, or whether we have an MDT meeting every week.
We’ve found that, because our CCG has been light touch with the DES, possibly because of the pandemic, we have been allowed to focus on the outcomes. We haven’t done care plans, we’ve done care planning – and care planning is a live approach that constantly updates and evolves. You could say the same with medication reviews.
Geetha I found the implementation went worse than expected because of Covid. We had a plan: we’d go in once a week; we’d see the patients; we’d do their SMRs. It didn’t go as expected. We’ve had to do a lot of virtual work and we’re just starting to pick up again.
Our care co-ordinators do the weekly ward rounds. At Covid times, if there were any outbreaks, the care co-ordinators would do a daily check-in with the care homes that were affected. The clinical pharmacists were in the background in case there were medication queries. The care co-ordinators also have a line to the pharmacist for other times when they have any medication queries.
The MDT meets once a month with the GP CD or the clinical lead. Some have nurse practitioner leads as well. We’re a little bit light on clinical input from GPs, and we don’t know whether we need more, but it seems like it’s working.
The point is, if clinically they are safe, and they’ve done what they need to do, I think practices, because of the workload, should let them get on with it.
Covid
Victoria: Clearly care homes were devastated by the pandemic and access to patients was limited. Can you discuss how Covid affected your EHCH service plans and delivery?
Paul The care home I work with suffered a significant number of deaths in those first three months. Some we couldn’t put down to Covid. Some we could because the testing wasn’t available and neither was the PPE. Those first three months, I was so proud of the staff and colleagues – I found it quite difficult to deal with emotionally because I’d built up a relationship.
I’ve spent the last 10 years in that home knowing a lot of those people. The matron at the home and the nurses and carers are as much of my staff as the practice nurses and my salaried doctors are.
I’m proud that of the people who died, none of them died in hospital. They all died peacefully in the home, even though they were not with their families.
I think that was a sign of accountability and trust and familiarity, [aspects] that this DES has failed to recognise. I’m surprised that doesn’t come through in the DES – the strength of continuity, familiarity, the coaching and mentoring of the staff [mean] that you give [them] the ability to trust, that [it] won’t go to the CQC just because they didn’t call an ambulance last night, that it’s excusable for people to have falls and things like that given the situation. I think the Covid situation highlighted that, because we were so dependent on the professionalism of these amazing individuals and Romanian nurses and Bulgarian carers, and people who made a real difference and weren’t championed in that first time.
Brigid It goes back to my point about [a situation where a patient like] Dolly is a bit unwell. You trust the assessment that care home staff have made because you know them, and you know that they know that person. They trust you if you say, ‘I’m sure this is fine, just put her to bed’. I think when you’ve built that trusting relationship, it trumps everything. The relational issues don’t come across in the DES at all and that’s disappointing. I guess you can’t bean-count them.
Rajiv In my practice, we have four nursing homes aligned to us, so we have one lead clinician linked to one care home, and roughly 35-40 people in a care home. So they have an established rapport with the staff, the manager and patients. That’s probably what helps through the pandemic time. It was so hard to look at the video and identify what was happening with all the PPE that staff were wearing. And the voice coming through [the screen] wasn’t very clear. [We had to figure out] what the care home people were saying to us [and then] relate it to what we know about the particular patient and the family demands and dynamics… To be honest, Covid had a big impact, but despite that, I would say it’s a positive experience of how we could help.
Brigid Our CCG provided some tablets [for remote working], but they were pretty rubbish and we had to use Zoom and that didn’t work terribly well. Sometimes we used WhatsApp on the carers’ phones. It was difficult not to go into our own care home.
But we could go [virtually] around the lounge, we could have a look at somebody’s foot, we could watch somebody walking across the room if there were worries about them. Actually I think it was better than might have been expected.
Victoria: Do you think you’ll continue to use technology in this way post Covid?
Brigid I don’t think the virtual visiting will stay, because assessing mobility and getting the feel for somebody is absolutely better face to face. But I think we’re all finding that using Microsoft Teams for the MDT discussions means you’re not travelling for half an hour, you can all fit into the same room, and there is an advantage in that. And if you can’t all be at the care home on a Thursday every week, maybe you can be once
a month, but in between times, you can have half-hour Teams discussions. We’ve got our virtual clinic with our geriatricians in the city who we can book a virtual appointment with to discuss anybody who’s complex. That wouldn’t have happened in the old world and it’s useful.
Katharine I think this is the question everybody’s grappling with – not just with the DES but with primary care as a whole. How much of this do we hold onto in terms of progress and how much of it do we stop? I think a hybrid will be the way forward, where after discussion we agree on the most appropriate way of consulting. We now have that option. In the pre-Covid world, I don’t think any of us would have considered doing a video consultation of an old frail person in a care home, and similarly a care home would never have accepted it. Also, they are doing lots of video calls with relatives, which has also improved their ease and confidence with technology. Certainly for us, with the number of homes we have, we will not be able to deliver the DES as a purely face-to-face model, so we are going to continue some kind of hybrid.
Funding
Victoria: Is the funding attached to this DES enough?
Katharine Short answer is probably not. Again, I think it comes back to the same thing – is it enough to tick the four main boxes of the DES? To do a care plan, a home round, an MDT and an SMR. Maybe it is for our population of care home residents. But is it enough to deliver high quality, individualised, community-based care, upskill our care home staff, our community teams and our ARRS roles and make this a resilient, sustainable, impactful DES? No. And is that a wasted opportunity? Absolutely.
Paul I totally agree with Katharine. It’s enough money to tick the box, but the boxes are not what is important here.
Our CCG pulled the money from the previous scheme and added it to the PCN scheme – I think that is probably enough and we’ve got the ARRS on top of it. It kind of all worked then, and a lot of it is core [funding] as well. So,
I think on its own, it’s not going to cover the costs of achieving the outcomes that I suspect they want us to achieve. I wish [there was an emphasis] on the outcomes and less about how to [achieve them].
Brigid We discuss: ‘Are the community nursing team paying themselves, or are we?’ Should we be paying for them out of our PCN money? In which case, [the DES funding is] absolutely not enough. And even if their services are paid from the community budget, there’s not enough. Also, seeing everybody post-discharge and within so many days [is] pretty ridiculous. We found out our specialist nursing team was making sure to see everybody within seven days of discharge and we didn’t even know that. Eventually, the GPs were going out and saying the nurse had done a review, but it had to be joined up. I think there’s a real issue with people desperately scrabbling around to do things they think they should do without a real overarching plan and vision.
Paul We all know [if we’re] looking after people with dementia, it takes at least a couple of weeks for them to settle in, to understand. The idea that you see them within two days… [if you have] a good registered mental health nurse-led nursing home, you don’t need to see them in the first two days.
Future
Victoria: A final question – what would you add to the DES to improve it?
Brigid Happiness of the care home staff. Let’s do some assessment of whether they are happy with the situation. Do they feel they are getting a good deal? Give them some boxes to tick.
Katharine Some kind of outcomes approach – but that outcome shouldn’t be admission avoidance, bed days saved, calls to 999. It should be dying in the preferred place of care, de-prescribing or medication burden – the wellbeing-focused, positive outcomes that we know make a difference to our patients. That should be the aim – not the boxticking, very fixed, very rigid criteria that have been set out so far.
Paul I’d add satisfaction of the care home manager – that they feel supported, have trust. [I’d add] more qualitative outcomes and more autonomy and fewer tick-boxes. [I’d also add] more autonomy for each PCN; and each practice to model how best it delivers on those outcomes, but with reasonable, good benchmarking and bellwether indicators.
Geetha I’d really like softer, qualitative indicators – indicators that involve the care home staff and relatives, to see if these [changes] have made a difference to families and patients.
