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Thursday, 15 December 2016

The Value of Care

Transitioning to value based care isn't easy

As I sit researching the facts for this article I find myself asking the same questions

1. Care Providers record their profit in various forms – The profit from properties, the profit from individual services operating under their umbrella and profit from capital.  Where’s this profit going?
2.    How much of this profit is reinvested back into their business?
3.    How much of this profit goes on the purchasing of company cars and other perks for Directors or other staff?
4.     How many care providers advertise are you seeking a care home or nursing home where people receive high-quality care in safety, comfort and a welcoming atmosphere?
5.   Or state claims that their personal activity coordinator ensures the people living here can follow the pastimes and pursuits they know and love. And they also encourage new interests inside and outside the home?
6.     How many of those residents are involved in their own care?

What is in fact the true value of Care?

In the 1990’s many of you will remember Councils sold off their Care Homes to private purchasers for example FSHC, Avery, BUPA and Excelcare. 

I worked in a Care Home during this transition.  Prior to the purchase of the home by a Private Purchaser my local council completely refurbished the premises.  New beds were purchased, brand new Oxford Hoists were purchased and special Hydrotherapy baths replaced the old-style baths.  Carpets were replaced and fresh paint adorned the walls. 

My local council spent an absolute fortune, admittedly the care was still of a poor standard but the home looked amazing!

When we were purchased, literally as soon as they took over, our brand-new beds were replaced with old style hospital beds, the brand-new hoists were sold or moved off site and the hydrotherapy baths were again removed from the premises and possibly sold.  But how much of the profit from selling these assets was put back into the service?  None?  How many other homes was this done to?

The manager who happened to be one of the few who cared was fired and replaced by “a company man” who I think had been an accountant manager at a supermarket prior to his placement as the Manager of the Care Home.  Now a Manager’s qualifications should be relevant to the care services your home provides, like health and social care, nursing, occupational therapy or social work but back then this wasn’t as regulated and DBS and CRB were still to happen.  Our new manager did not know Care and did not care.

After the purchase, and the selling off all the assets by the new Provider, care standards slipped to an all-time low, safeguarding once again became an issue and abuse within the home was apparent and those who reported this found themselves with their P45 and a UB40 card.

After I left, I went to work in Adult Social Care and was placed within the Safeguarding Department.  This was at the time a new department, and still in it’s infancy.  In my first year in Safeguarding this same home and horrific cases of abuse passed over my desk at a ratio of 1:4, for every 20 cases on my desk 5 were relating to this Service Provider and this care home.

Lessons were always “leant”, outcomes were always recorded and recommendations were always made.  But nothing ever changed, staff were never dealt with appropriately and the standard of care was still below any decent expectation.

Moving on nearly 20 years and I still find nothing has changed.  And I’m still asking the same questions.

How can we improve care in residential homes as the needs of older people intensify?

In the next 20 years, the number of older people in England will rise significantly. 

As we all live longer, the need for more places in good quality homes will intensify.

Value-based care isn’t a new concept, true value-based care: fully capitated payment contracts in which a lump sum of money is available to treat a patient over the course of a year.  No penalties or incentives, simply ownership of the total cost of care and the total cost of outcomes.  The better the care, the more money the organisation bearing the risk receives.  This is how to best reward exceedingly efficient, effective health care.

But to create the value, you must first invest.  Invest back into the services, the staff and the Users who are purchasing their care.  Policy and Procedure needs to be re-evaluated and encompassing of the needs of the many not just the needs of the service or solely the profit margin.

Partnership working between district nurses and care home staff still appears largely to occur by default at present.  There is opportunity for a more strategic approach to providing nursing support in residential homes.

There is considerable debate about the relationship between quality of care and quality of life, but why should these be competitive?  Should one not work with the other?

There is clear evidence of unmet needs amongst older people with dementia, poor quality of life, and inappropriate use of psychotropic drugs.

In other clinical conditions, staff training appears to produce improvements in residential homes, but seems unsustainable by the Provider.  What about other areas of training (e.g. infection, rehabilitation, preventive care).  There is some literature on improving the nutritional status of older people in residential care, but how many care homes have implemented this?

There is a clear need for better management of medication in nursing homes.  Appropriateness of drug use is an important indicator of the quality of care.

Older adults who are hospitalised can decline in a matter of days, emphasising the importance of timely hospital discharge. Evidence suggests that stroke patients in nursing homes are less likely to receive physiotherapy or occupational therapy than those in hospital-based extended nursing care and that patients discharged to a nursing home have a greater risk of dying. Placement in nursing homes after stroke discharge needs to be better understood to manage length of stay and the cost of acute care.

Together we can improve upon care in care homes as the needs of older people intensify.

With aims to clarify the agenda for policy-makers and practitioners.

Better integration of services for older people which has long been promoted as improving quality of care and potentially reducing costs.

Quality improvement interventions include monitoring quality of care, strengthening the care-giving workforce through training and regular Training Audits.

Person-Centred oriented care focuses on quality of life.  Factors considered include resident activities, social contacts and staff knowledge and evaluation of individuals.  This approach can reduce care gaps, particularly in psycho-social aspects of care.  It can also have a positive impact on staff e.g. lower frequency of sick leave.  

We can promote independence and trust based relationships between care staff and residents.

Management and leadership style have an important impact on quality improvement initiatives, change must begin with owners and managers building new relationships with all stakeholder’s.

Stakeholder’s are (in a pictorial diagram): but also, includes CCG’s, NHS, Associated Organisations and Local Authority Commissioning Services

Pictorial discription of stakeholders

New work practices may be insufficient if adopted without investment in training or a commitment to continued Training and Practice.

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