During Wave 1 of the Population Health Management work, LS25/26 targeted work at people living with severe frailty and dementia. 221 people were identified, and out of this 221, 40-50 people were reviewed, which showed a high percentage of this review cohort did not have an advanced care plan recorded in Systm1.
To rectify this, the LCP aimed to get an up to date, agreed, shared and visible Advanced Care Plan (ACP) in place for these individuals in order to reduce hospital admissions and make sure people were cared for in the way they wanted. In order to do this and use the expertise of people involved in a person’s care, a full MDT was tried in care homes with care home staff, the resident, carers and health professionals to discuss ACP. Although very time consuming, outcomes were very positive.
Hence to support this model, it has been agreed it would be beneficial to trial a coordinator role to pull all of this together, known as a Planning Ahead Coordinator.
A Planning Ahead Coordinator started in August. The Planning Ahead Service supports patients with frailty to engage with discussions about their future care options, including topics such as What Matters to Me, preferences for future care, Power of Attorney, will making and funeral planning. Depending on the patient’s wants and needs, signposting to local organisations and referrals to talk about advanced medical decisions are available too.
The service operates in the patients’ homes, with Jo visiting the patient and any other people involved in their care, i.e spouse or their children. The conversations are patient-led, with information and advice available in the form of booklets to keep. The conversations are recorded onto the Planning Ahead Template on System 1, including the Recommended Summary Plan Emergency Care Treatment (ReSPECT) form of which a copy is shared with the patient, who is then advised to share their future care plans with their loved ones and carers and display their ReSPECT form in their care plan or somewhere accessible (fridge/noticeboard) so that visitors to the home involved with caring for the patient (paramedics or new carers) can know the patient’s wishes.
Challenges associated with delivering the Planning Ahead Service include the emotive nature of the conversations as well as making sure everyone is heard. Successes of Planning Ahead Service include the areas of conversations covered, patient’s wishes being recorded onto the Planning Ahead Template and the thanks and comfort the patients expressed. The Planning Ahead Service is currently developing what will count as measurable outcomes for success, both in relation to quantitative and qualitative data.
So far, the referrals to the service are picking up, and feedback has been very positive – case study available here. A steering group has been formed to link the role into other pieces of work and consider how best to evaluate this model.
Work has been going on under the LS25 & LS26 Local Care Partnership to work together to tackle Obesity. As an LCP, we are an outlier in the city for obesity data. This means we have a higher percentage of people who are registered as obese (with a BMI over 30) in this locality. This information comes from GP practices in this PCN.
Pre COVID, the PCN undertook a survey with all of their patients to understand their attitudes to diet and exercise. This data showed us that we had a priority population of women who were 45-60 living with obesity, but also showed us that the top way people felt they could improve their lifestyle was by taking part in more physical activity.
In September 2020 we launched an online survey facilitated by Health Watch Leeds to understand how people’s attitudes to diet and exercise have changed in light of the COVID 19 pandemic. We also wanted to find out what mattered to people locally to help us find a local narrative for whatever next steps we take in this project. You can find the write-up and action plan here.
In December 2020, the LCP, spearheaded by Active Leeds, were successful in a bid to the West Yorkshire and Harrogate Partnership for money to implement and embed 15-minute neighbourhoods; a behavioural change that gets local people to swap quick car journeys for walking, cycling or scooting to key destinations, such as town centres, medical services including pharmacies and local green spaces, which are in the region of 15 minutes away. Active Travel solutions have been co-produced with local people, and as a first step, the project is looking at better mapping local walking and cycling routes in the area.
As a partnership, we are keen to learn more about each other’s services and roles in the community. We are also keen to have varied focuses so are open to new opportunities to develop as a partnership whilst improving the lives of the local population.
We are keen to include more partners across the patch, in particular those who can support our current priorities and community groups. If you would like more information or to join us, please contact email@example.com.