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Schedule 2 SERVICE SPECIFICATION Service ENHANCED NURSING HOME BEDS Commissioner Lead Stephanie Lawrence Provider Lead Konrad Czajka Period 1st April 2013 – 31st March 2014 1. Purpose 1.1 Aims To commission intermediate care beds in a care home facility with appropriate care and nursing support. targeted at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long term residential care, or continuing NHS in-patient care; provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery; has a planned outcome of maximising independence and enabling the client to resume to living at home; Is time-limited, normally no longer that 2 weeks or 4 weeks dependent on which bed the patient is admitted to. involves cross-professional working, within a unified assessment framework, single professional records, shared protocols and accessed via a single point of access. 1.2 Evidence Base The multi-disciplinary Airedale Collaborate Care Team will utilise these beds to reduce the requirement for the Airedale Intermediate Care Ward as part of the Intermediate Care system redesign within Airedale and Wharfedale and Craven area. 1.3 General Overview To provide a community bed-base to facilitate “step up” and “step down” bed base in the community. 1.4 Objectives To facilitate the transition to functional independence so that the client may return to their usual place of residence within a pre-defined period of time. 1.5 Expected Outcomes Avoidance of unnecessary admission to hospital Support for the transition from hospital to home Avoidance of preventable or premature admission to long term residential or nursing home care Programme of residential rehabilitation 2. Scope 2.1 Service Description Provision of 10 enhanced nursing home beds; The beds will be accessed only via the Airedale Collaborative Care Team ** (the Airedale Wharfedale and Craven CCG’s single point of access for all intermediate care services) by hospital and community based professionals across health and social care, adhering to the admission criteria for the service. Medical/Nursing Page 1 of 7 Schedule 2 admission criteria found in the Operational Policy – available in Schedule 2 The Services G. Other locally agreed policies and procedures. It is a requirement that the beds will be provided from a registered nursing home and have current QS3 (VTE Prevention) accreditation with a verification visit undertaken this year. ** The Airedale Collaborative Care Team is a multi-disciplinary team, comprising: Hospital consultant, GP, specialist nurses, community matrons, therapists, support workers, social and care workers 2. Service Overview The beds will be required to facilitate two functions: 1) Beds to prevent admission into hospital. 2) Beds to primarily facilitate discharge from hospital. There will be some flexibility on how many beds will provide each function and this will be agreed with the individual care home and the Airedale Collaborative care Team This will be a short stay facility (maximum of 2 weeks for the function to prevent admission to hospital and a maximum of 4 weeks for the function to facilitate discharge, longer in exceptional circumstances following review through the Collaborative care Team). The Service Provider will nominate a number of dedicated staff to promote a rehabilitation focus and ensure continuity of care. This will foster good working relationships and increase communication pathways with the dedicated nursing home staff and multi-disciplinary intermediate care team visiting the home. The Service Provider will provide a co-ordinator to oversee the management and use of the designated beds and liaise with relevant health and social care professionals, who will work with patients who are admitted to these beds, for example physiotherapists, occupational therapists, GPs, social workers, consultant geriatricians Their medical care will be monitored by the patient’s General Practitioner or temporary General Practitioner (where applicable) in collaboration with the hospital outreach team. The Service Provider will receive support from the Airedale Collaborative Support Team consisting of a multidisciplinary team of nurses, therapists, rehabilitation assistants and social worker input, together with consultant geriatrician input, to ensure appropriate case management and discharge arrangements either back home or to an alternative setting. The care provided and facilities within the home must meet the National Minimum Standards and requirements set out in the ‘Care Homes for Older People – National Minimum Standards – Care Home Regulations 2001’ (3rd Edition, DH, 2001) and in line with the principles and standards outlined in the National Service Framework for Older People (DH, March 2001), and meet the requirements for the National Service Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (DH 2007). 2.2 Accessibility/acceptability Medical/Nursing admission criteria found in the Operational Policy – Schedule 2 , G. Other Policies locally agreed 2.3 Whole System Relationships The aim of the service is to commission intermediate care beds in a care home facility with appropriate care and nursing support that will be available for use by the Commissioner. Following assessment by the Airedale Page 2 of 7 Schedule 2 Collaborative care Team and the named nurse from the home, patients whose intermediate care needs can be met by the hospital outreach team and/or Collaborative care Team can be transferred into this facility. The admission will be jointly coordinated by the Collaborative care Team and the home. 2.4 Interdependencies The Airedale Collaborative care Team is a multi-disciplinary team, comprising: Hospital consultant, GP, specialist nurses, community matrons, therapists, support workers, social and care workers. 2.5 Relevant networks and screening programmes 2.6 Sub-contractors 3. Service Delivery 3.1 Service model The beds will be required to facilitate two functions: 3) Beds to prevent admission into hospital. 4) Beds to primarily facilitate discharge from hospital. There will be some flexibility on how many beds will provide each function and this will be agreed with the care home and the Airedale Collaborative Care Team This will be a short stay facility (maximum of 2 weeks for the function 1 beds to prevent admission to hospital and a maximum of 4 weeks for the function 2 beds primarily to facilitate discharge, longer in exceptional circumstances following review through the Airedale Collaborative Care Team). It is expected that the home will nominate a number of dedicated staff to promote a rehabilitation focus and ensure continuity of care. This will foster good working relationships and increase communication pathways with the dedicated nursing home staff and multi-disciplinary intermediate care team visiting the home. There is a requirement for the Service Provider to provide a co-ordinator to oversee the management and use of the designated beds and liaise with relevant health and social care professionals, who will work with patients who are admitted to these beds, for example physiotherapists, occupational therapists, GPs, social workers, consultant geriatricians Their medical care will be monitored by the patient’s General Practitioner or temporary General Practitioner (where applicable) in collaboration with the hospital outreach team. The Service Provider will receive support from the Airedale Collaborative Care Team consisting of a multidisciplinary team of nurses, therapists, rehabilitation assistants and social worker input, together with consultant geriatrician input, to ensure appropriate case management and discharge arrangements either back home or to an alternative setting. The care provided and facilities within the home must meet the National Minimum Standards and requirements set out in the ‘Care Homes for Older People – National Minimum Standards – Care Home Regulations 2001’ (3rd Edition, DH, 2001) and in line with the principles and standards outlined in the National Service Framework for Older People (DH, March 2001), and meet the requirements for the National Service Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (DH 2007). Page 3 of 7 Schedule 2 4. Referral, Access and Acceptance Criteria 4.1 Geographic coverage/boundaries Scheme available to patients registered with an Airedale / Wharfedale or Craven GP 4.2 Location(s) of Service Delivery Currergate Nursing Home 4.3 Days/Hours of operation 4.4 Referral criteria & sources See Operational Policy – Schedule 2 , G. Other Policies locally agreed 4.5 Referral route See Operational Policy – Schedule 2 , G. Other Policies locally agreed 4.6 Exclusion criteria See Operational Policy – Schedule 2 , G. Other Policies locally agreed 4.7 Response time & detail and prioritisation See Operational Policy – Schedule 2 , G. Other Policies locally agreed 5. Discharge Criteria & Planning including End of Contract “Phase out” plan See Operational Policy – Schedule 2 , G. Other Policies locally agreed 6. Information Reporting The Provider will submit to the CCGs Contracting Team the following information on a monthly basis to facilitate payment:1) Occupancy Tracking Sheet 2) Copies of Patient Questionnaires completed The Commissioner may from time to time notify the Provider of what further information it may reasonably require in order to monitor the Provider’s performance of this Agreement, and in particular the Provider’s compliance with Quality Standards, and the Provider shall supply such information. Page 4 of 7 Schedule 2 Quality Performance Indicator Threshold Method of measurement Infection Control Service User Experience Improving Service Users & Carers Experience Unplanned admissions Reducing Inequalities Reducing Barriers Improving Productivity Access Care Management Outcomes Additional Measures for Block Contracts:Staff turnover rates Sickness levels Agency and bank spend Contacts per FTE Page 5 of 7 Consequence of breach Report Due Schedule 2 8. Activity 9. Continual Service Improvement Plan 10. Prices & Costs 10.1 Price Basis of Contract Unit of Measurement Price Cost per bed per week Vacant bed £700.00 Cost per bed per week Occupied bed £749.00 Maximum 10 Beds Page 6 of 7 Schedule 2 Page 7 of 7