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The framework for enhanced health in care homes

1.1 Across England, six vanguards are working to improve the quality of life, healthcare and planning for people living in care homes. One in seven people aged 85 or over is living permanently in a care home. The evidence suggests that many of these people are not having their needs properly assessed and addressed. As a result, they often experience unnecessary, unplanned and avoidable admissions to hospital, and sub-optimal medication.

1.2 Within these six vanguard areas, care homes are working closely with the NHS, local authorities, the voluntary sector, carers and families to optimise the health of their residents. The enhanced health in care homes (EHCH) care model is an adjunct to the other new care models that are delivering whole population healthcare. It will become a core element of the multispecialty community provider (MCP) and primary and acute care system (PACS) models.

1.3 We have co-developed this document with the six EHCH vanguards and our partners in social care. The EHCH model is based on a suite of evidence-based interventions, which are designed to be delivered within and around a care home in a coordinated manner in order to make the biggest difference to its residents.

1.4 Many of these interventions are well known. Some areas of the country will either have established some of these interventions already or will have been working towards them for a number of years. The work within the EHCH vanguards is therefore the culmination of many years’ worth of work to improve the wellbeing and care of care home residents. By bringing a range of commissioners and providers together, solutions have been developed in a coordinated way, which has meant that vanguards can implement changes which would not be possible if done in isolation.

1.5 A 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 in residential settings.

1.6 In many parts of the country, the care for people who are living in care homes or who are at risk of losing their independence is being held back by a series of care barriers, financial barriers, and organisational barriers:

• Care barriers
- A narrow focus on medical rather than holistic needs
- Lack of integrated care planning that focuses on prevention and pro-active care
- Variable access for care home residents to NHS services
- Lack of continuity of care and the difficulties faced by the current workforce crisis

• Financial barriers
- Few system-wide incentives around preventative care across health and social care providers
- A financially distressed care provider market which will impact on quality in some care homes
- The financial challenges that the national living wage and other centrally imposed cost increases put on the finances of the providers and local authority/clinical commissioning group commissioners
- Recruitment and retention (including training) within the care sector
- Contractual mechanisms for provision of preventative health care for those in care homes and those at risk of losing their independence

• Organisational barriers
- Barriers between organisations in different parts of the health service and between the NHS and other sectors, in particular social care
- A lack of financial and clinical accountability for the health of the defined population
- Variations in policy, process and supporting systems (such as information technology (IT)) across organisations.

1.7 This new care model seeks to overcome as many of these challenges as possible by ensuring that:

• people have access to enhanced primary care and to specialist services;
• budgets and incentives are aligned so that all parts of the system are unequivocally focussed on improving people’s health and wellbeing;
• the working environment is optimised for staff employed by social care providers so that they feel at the heart of an integrated team that spans primary, community, mental health, and specialist care, as well as social care services and the voluntary sector;
• people maintain their independence as far as possible by reducing, delaying or preventing the need for formal social care services;
• health and social care services are commissioned in a coordinated manner, and the role of the social care provider market is properly understood by commissioners and providers across health and social care.

1.8 This EHCH framework applies equally to people who self-fund their care and to people whose care is funded by the NHS or their local authority: everyone has the right to high quality NHS services. The ‘footprint’ of an EHCH is all of the care homes (residential and nursing) that are situated in the planning footprint that chooses to implement the EHCH model, be it a sustainability and transformation plan (STP) area, a clinical commissioning group (CCG), a local authority or an MCP or PACS. Its scope may therefore include certain reablement and rehabilitation services that are provided in the community and which are aimed at avoiding unnecessary admission to hospital or into a care home; however, all aspects of the care described in this framework will need to be tailored to local circumstances and to each individual person’s care needs.

1.9 In order to help deliver a person-centred approach to care and support, the emerging EHCH framework draws on both the ‘I statements’ (published by the ‘Think Local, Act Personal’ (TLAP) partnership that spans the health and social care sector) and the ’My Home Life’ initiative (that promotes quality of life and delivers positive change in care homes for older people).

1.10 Through the process of developing the EHCH care model, we have also become aware of a range of ‘small, big ideas’. These are defined as simple ideas that - if done well and replicated elsewhere - will not by themselves solve the significant issues being faced but may improve the quality and outcomes of care for care home residents. Wh