North Central London (NCL) is adopting integrated care networks and working with a multi-disciplinary team approach through delivery of support to care homes in Enfield. Whilst the primary goal of health and social care services is to support people in their own home for as long as possible, if this is no longer possible, we must ensure that the best possible care is provided to those needing care homes. Older people in care homes are amongst the most frail, vulnerable and dependent populations in our communities. As well as physical health conditions, 80% of people living in care homes have dementia and people with dementia have worse outcomes when admitted to hospital.
Therefore, this report seeks to give commissioners, partners across health and social care and care homes a best practice example of how to remove barriers between primary and secondary care, physical and mental health, health and social care through an integrated multi-disciplinary team supporting care homes in Enfield called the Care Home Assessment Team (CHAT). CHAT is an integrated mental and physical health team of Community Matrons, Geriatricians, Consultant Psychiatrist and Mental Health Nurses, occupational therapy, a phlebotomist, a tissue viability nurse, pharmacists and has strong links to primary care and frailty networks, who support 39 care homes across Enfield.
The outcomes
- There was 35% reduction (-2,118) in the total number of A&E attendances and non-elective admissions, compared with a 23% increase in Enfield’s 65+ year old non care home population.
- This equated to a 9% reduction in costs (-£598,671). Against a 34% increase in costs for the general population aged 65+ (+£7,113,284)
- Falls leading to hospital attendance or admission were reduced by 7%
- 99% of residents died in their preferred place
- 39% of residents have had their medication reduced or stopped
- 8,409 hospital attendances and 8,109 GP call outs have been avoided
- 7,606 care home staff and managers attended training on 59 subjects
Good practice guides and checklists
- Executive Summary Enfield Chat report: Improving the lives and deaths of residents in care homes
- Full report: Supporting older people’s mental health: Enfield’s Care Home Assessment Team
- Dementia sight loss deisgn guidance
- Fall Checks
- Falls if someone falls
- Falls CHAT Team – Falls Clinic Promforma
- Falls Post Assessment
- Falls Risk Assessment tool
- Falls Staff Knowledge Questionnaire
- Falls Staff lead in a care home
- Medication and falls
- PIMP my Zimmer
- Safe shoe checklist
- Geriatric assessment in care homes new resident review
- Advanced care planning ACP Template
- Advanced care planning for peope with dementia
- Advanced care planning decisions to CPR
- Hospitals tools for dementia care bundle quick guide
- Diagnosing mental health in care homes DiADem Tool
- Diagnosing mentak health in care homes geriatric depression scale short form
See also:
- Blog: Showcasing achievements for the care of older people, Alistair Burns, CBE FRCP, FRCPsych, MD, MPhil
- Camden and Islington NHS Foundation Trust Care Home Liaison Service
In the three years that the Care Home Multidisciplinary Teams have been established, the ICAT’s data shows that:
- Acute admissions to the Whittington Hospital have fallen from 32.5 to 24.2 per month
- There has been an 18% reduction in bed days, despite an 8% rise in length of stay.
- To read the full report about depression in care homes and the best practice example by Camden and Islington NHS Foundation Trust ‘s Care Home go to Care Home Liaison Service report, see page 10&11