PCN service specification: Enhanced health in care homes

A summary of the draft service specification published by NHS England

The document states that the aim of the Enhanced Health in Care Homes (EHCH) service is to:

• Improve the experience, quality and safety of care for people living in care homes, their families and their carers;
• Reduce avoidable ambulance journeys, A&E attendances and emergency admissions to hospital for people living care home residents;
• Improve sub-optimal medication regimes in care homes; and
• Support more people living in care homes to die in a place of their choosing.

The service covers people who live permanently in care homes – including people living in residential and nursing homes that deliver specialist support, such as specialist learning disability and dementia units, but not people living in secure units for mental health.

Service requirements

These focus on national roll out of the first four clinical elements of the ‘EHCH framework’:

• enhanced primary care support;
• multidisciplinary team support;
• reablement and rehabilitation; and
• high-quality end-of-life care and dementia care.

The service requirements are shared across PCNs and other providers, particularly community services, who are expected to work together to deliver the model.

The specific requirements detailed for PCNs are:

1. By 30 June 2020 PCNs must identify a clinical lead who will be responsible across the PCN for the delivery of the service requirements.

2. From no later than 30 June 2020, ensure every person living permanently in a care home has a named clinical team, including staff from the PCN and relevant providers of community services, who are accountable for the care delivered through the EHCH model.

3. From no later than 30 June 2020, ensure every care home is aligned to a single PCN, and its multidisciplinary team (MDT), which is responsible for supporting that care home and delivering the EHCH service for people living in that home that are already registered with a practice in the PCN or choose to register with a practice in the PCN.

By 30 June 2020 each PCN will agree the care homes for which it has responsibility with its CCG. People entering the care home should be supported to re-register with the aligned PCN and have the benefits of doing so clearly explained.

Where people choose not to register with a practice in the aligned PCN, requirements 4-9 below should be delivered by their registered practice, either directly or through local sub-contracting arrangements.

4. From no later than 30 June 2020, establish and manage a multidisciplinary team (MDT) of professionals, working across organisational boundaries to develop and monitor personalised care and support plans, and the support offers defined in them, for people living in care homes.

5. From no later than 30 June 2020, establish protocols between the care home and wider system partners for information sharing and shared care planning, use of shared care records and clear clinical governance and accountability.

6. From no later than 30 September 2020, deliver a weekly, in person, ‘home round’ for their registered patients in the care home(s). The home round must

• be led by a suitable clinician. On at least a fortnightly basis this must be a GP. With local agreement the GP can be substituted by a community geriatrician.
• involve a consistent group of staff from the MDT.
• focus on people identified for review by the care home, those with the most acute and escalating needs or those who may require palliative or end-of-life care.

7. From no later than 30 September 2020, own, and coordinate delivery of, a personalised care and support plan with people living in care homes based on relevant assessments of needs and drawing on assessments that have already taken place where possible and:

• ensure that this plan is developed and agreed with each new resident within seven days of admission to the home, and within seven days of readmission following a hospital episode. Review the plan when clinically appropriate and refresh it at least annually;
• ensure the plan is developed with the person or/or their carer, and reflects their personal goals;
• ensure the plan is tailored to the person’s particular needs (for example if they are living with dementia) and circumstances (such as those people approaching the end of their life).

8. From no later than 30 September 2020, coordinate, alongside community providers, one-off or regular support to people within care homes, based on the needs defined in the personalised care and support plan and those identified by care home staff.

Directly deliver or support delivery of elements of this support where appropriate, including:

• structured medication reviews (SMRs), delivered according to the requirements of the SMR specification.
• activities to support the achievement of goals identified as important to the person in their personalised care and support plan, including reasonable efforts to build links with local organisations outside of the home.

9. From no later than 30 September 2020, provide, through the MDT, identification and assessment of eligibility for urgent community response services

10. Provide support and assistance to the care home by:

• supporting the professional development of care home staff by identifying opportunities for training and shared learning;
• working with the care home and wider system partners to address challenges the home is facing in coordination with the wider health and care system;
• delivering relevant vaccinations for care home staff, in line with the provisions set out in the seasonal influenza DES.

11. From no later than 30 September 2020, working with the CCG to establish processes that improve efficient transfer of clinical care between residential homes, nursing homes and hospices and between

care homes and hospitals.

Facilitate and support local and national initiatives to support discharge from hospital and psychiatric inpatient units, such as trusted assessor schemes.

12. From no later than 30 September 2020, establish clear referral routes and information sharing arrangements between care homes, PCNs and out of hours providers and providers of a full range of community-based services including specialist mental health, dietetic, speech & language therapy, palliative care and dementia care.

Metrics to assess PCN performance in delivery of this service:

1. The rate of urgent care attendances for people living in care homes.

2. The proportion of people living in a care home who have a personalised care and support plan in place.

3. The number of people living in a care home who receive an appointment as part of the weekly care home round.

4. The number and proportion of people living in a care home who receive a structured medication review.

5. The number and proportion of people living in a care home who receive a delirium risk assessment.

You can access the full draft specifications document here.