Agenda

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uaLe: 16
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!uly 2014
1lme: 09:00 - 11:00
venue: Med 2 Semlnar room WesL Cornwall PosplLal, enzance
Lead 1lmlng
(Mlns)
1. Welcome and Apologles Chalr 10
2. l1 updaLe aul !acka 20
3. CuLcomes lramework and uashboard L8 20
4. CommunlLy 8oard - uashboard ulscusslon S8 20
3. Llvlng Well ManagemenL lan C8 20
6. Work SLream updaLes and uellverables 1eam 20
7. CperaLlonal 8eporL 18 10
8. revlous MeeLlng 8ecord
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9. Any CLher 8uslness Chalr 10
10. uaLe of nexL MeeLlngs
17
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SepLember 2014 [ 9:00
luLure meeLlngs every 3
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1


LIVING WELL MANAGEMENT PLAN

Date: 18-03-14
V.01

Goals:

To live the life people want to the best of their ability
To support people to be as independent as possible
To reduce the reliance on formal care and health services

Actions to support self management by the Changing Lives workers and volunteers:
Have a conversation about circle of support, including formal and informal carer support and
social networks. Review links to activities and the creation of home or day activity.
Support the person to keep active and socialise as much as possible doing the things they
enjoy.
I live alone or have some one living with me? If I live alone am I bereaved?
Do I have caring responsibilities or does someone care for me? I am or my carer is coping well
with my/their responsibilities?
I have a healthy diet that includes 5 portions of fruit/vegetables daily, starchy foods make up
one third of my total diet, two portions of protein a day, and three portions of dairy products a
day. (Age UK 2012) Experts recommend that I have a dietary intake of 700 milligrams (mg) of
calcium and 10 micrograms (mcg) of vitamin D a day. I sometimes have difficulty in swallowing
my food or drinks.
I have regular drinks and my wee is clear or straw coloured.
My clothes no longer fit me, they are too tight/too loose.
I dont have any problems getting to the toilet on time. I dont suffer from constipation.
I dont just sit in my chair all day, I get out and about with the dog, gardening, gym, vacuuming
etc
I trip and fall easily, the last time I feel was!..
I can lift heavy plates out of the top cupboard and find it easy to go up and down stairs.
I struggle to hear people speaking.
I think I need new glasses
I sometimes get muddled, I am muddled most of the time, I think clearly.
I sleep well, I have trouble sleeping, I power nap
I have my flu jab every year and have had pneumonia vaccine.
Do I have any pain and do I take my pain killers as prescribed.
Can I cook and feed myself and keep my home clean and tidy as well as doing my own
shopping.
I drive my own car
I manage my own money
I manage my own medications and take them as prescribed.
Is the home accessible and safe: Check the following:



2
My Nursing Team Actions:

Promote all self care advice above at every visit.
Discuss any changes to health status with community matron or GP then optimise LTC
management
Malnutrition can worsen prognosis for older frail people assess using the MUST tool at least
every three months and act on the recommendations.
Prescribe calcium and vitamin D supplements if housebound
Ensure all medications including pain relief and preventative therapy (aspirin, statin etc) are
taken as prescribed.
Be suspicious of medicine induced falls if taking lots of tablets. Carry out a 5QT falls
assessment monthly
Take every opportunity to reduce numbers of medications taken. Reduce or stop
benzodiazepine and sedative use.
Look out for low blood pressure on standing monitor lying and standing blood pressure
monthly.
My GP Actions:






3


EXACERBATION MANAGEMENT

Some clinical signs and symptoms may indicate an exacerbation or crisis approaching but frail older
people often do not present typically. Think:

Multi-pathology many conditions and their treatment interacting and causing problems
Medications adverse effects of medications any new medications, are the doses correct?
Social & environmental issues impact of the environment and reduced coping mechanisms
Mental health is the patient depressed, is there any evidence of cognitive impairment?

Actions to take:

Review medication what could be causing the problem? Discuss with CM or GP
Review the social/environmental circumstances has there been a change? Consider
OT/Physio referral and equipment.
Assess mental health use Geriatric Depression Score or 6CIT refer if required
Discuss where people feel they score on the living well scale and discuss at the MDT if a
referral for a Comprehensive Geriatric Assessment would be beneficial?

RED FLAG SIGNS AND SYMPTOMS

WHEN TO GET IMMEDIATE ADVICE FROM COMMUNITY MATRON/GENERAL PRACTITIONER

A sign or symptom that is different from the normal for that patient:

Swollen ankles and feet
Shortness of breath
Cough & sputum
Chest pain
Confusion or drowsiness
Onset of falls
Dizzy, Light headed
Limb weakness/facial palsy/slurred speech (FACE symptoms)
Vomiting
Incontinence/frequency worsening
Off legs
High temperature
Lack of appetite/weight loss
Altered bowel habit




Meeting Record

Meeting: Penwith Project Board
Date: 18
th
June 2014
Time: 09:30 11:30
Venue: Med 2 Seminar Room, West Cornwall Hospital

Key Discussion Points
Goverence Framework
o Framework needs to ensure quality of services Outcomes and Impact
o How will risk be managed/shared with the community
o The Community Board will have a whole population approach
o What are the links with the LEP, CSP, LNP and the Public Sector
Group
Single Access Point
o There will be a locality single point of access, but any door will be the
right door. That will be publicly facing.
o Not 24/7 but long day, staffed by Guided Conversation trained staff
o The volunteer will be at the frontend
o Next step is what happens next
o How many calls do we have a day coming into the locality and how
much time does it take to handle all of the calls
Local People Local Conversations
o Pulling together and linking people and networks
o Volunteer Cornwall to be the link for all of the volunteer recruitment
o Shaped by Website looking at how you can bring people together
around a community a challenge
o Commissioned review of voluntary sector skills and training
required for MDTs and care coordination; to start once NESTA
funding agreed
o Publicity Finacial Times Interview, Nursing Times etc
Workforce
o How do we link in the students on Health and Care courses?
o The strategic workforce group is reviewing how education is delivered
o Covered in the up date on the single point of access
Integrated Commissioning
o Joint Stretgic Comissioning Executive Committee is now established
o Transformation board ---PROJECT TEAM not Board --- has now been
established
Information Governance and Technology
o Produce prioritised work plan for Informatics group
o Agree governance on how we will share cost/activity data to measure
success in Penwith
o Progress with Monitor PILs pilot
o Agree and utilise accredited Safe Haven
o Agree and prepare Digital Technology Fund bid
o Prepare options appraisal for interoperability tool
o Implement NHS number in Social Care record
o Progress with financial modelling project and agree tool (Redbridge,
Symphony, local)

Outcomes and Intelligence
o The evaluation framework is nearly finalised
o The dashboard is nearly in place
Asset Utilisation
o Fire regulations have been covered
o Bradbury Fund Age UK can apply this may cover the cost of the
redevelopment
Operational Update
o 2 people on the programme have become volunteers to support others
on the programme.
o See case study in appendices
o Age UK staff need to be more proactive in going into the practices so
that pushing people across
o Extra member of the staff now on the ground to help delivery
o It is the first week of Full of Life fortnight

Decisions
The locality board will be called The Community Board

Actions Owner Deadline/
Completed
1. Circulate ACPO National Decision Model, roll out to all
work streams and all members to try before next
Meeting
JW/SB/All !
2. Leadership Summit to adopt ACPO National Decision
Model
TR/AA !
3. HWBB to adopt ACPO National Decision Model JM/SB/JW Feb 2014
4. Pioneer National Team to review ACPO National
Decision Model
JL Feb 2014
5. Present the Pioneer Programme to the Town and Parish
Councils in Penwith
JM/SN to
arrange
!
6. Meeting with Editor of The Cornishman/West Briton JM to
arrange
!
7. Leadership Summit to be asked to define their 5 year
vision
AA/TR Mar 2014
8. Network Leadership Group to be briefed on the Penwith
Pioneer
NW/MB !
9. Stocktake of the programme Team !
10. Develop links to neighbourhood watch JW May 2014
11. Identification of staff car parking in St Erbins car park JM May 2014
12. Identification of 150k capital for shared office JM/AA May 2014
13. Discuss estate options with Bishop SB !
14. First draft of Dash Board to May meeting ER May 2014
15. Bring Living Well Management Plan to June Meeting GR July 2014
16. Approach the HWBB and Rob Andrew for some
community resource
AA/JW June 2014
17. Invite local policing teams to locality meetings JW/GR !
18. Primary Care IG led needs to be identified ER April 2014
19. Locality Goverence Model Group TR/DR/AT June 2014
20. Link with Health and Care courses TR/SB July 2014

Living Well in Cornwall

Programme: Penwith Programme
Author: Tracey Roose and Scott Bennett
Date: 09
th
July 2014

1. Progress since last meeting / against plan / deliverables:




















2. Issues requiring discussion / resolution / support:


3. Actions before next meeting:





! Financial modelling highlight report headlines are:
o Developing and agree the financial resource taxonomy
o Developing data on financial resource consumption by geography
o Developing and agreeing the demand forecasting approach by framework
o Alignment of the outputs of financial modeling with the commissioning cycle is in
discussion
o Discussion with Locality Groups to take GP views on the approach to financial modeling
! On going testing of the outcome framework with all providers and commissioner
! Operational progress continues to progress, GP champions have been identified to drive referrals
back on target
! Community conversations continue to build rich picture of individual, group and organisational
assets
! Stakeholders agree to information governance approaches to facilitate the analysis through
Informatics group
! Developing specification to respond to provider and commissioning views
! Working group working on first iteration of evaluation to ensure data collection
! Scoping and development of options and implementation plan for the co-designed community
line and access points for Penwith; included a meeting with CEO BT Cornwall and Global
Partnership Director
None noted for this period.
" Penwith Board Meeting on Wednesday 16
th
July; locality practitioner meeting also on 16
th

" Community Board working group meeting to shape asks governance asks
" Design of the Dashboard to be agreed
" The Health and Wellbeing Board will be updated on progress; review of San Diego approach to
whole population impact indicators
" Practices to be approached to develop and test the Community Line approach and continued
discussions with BT, technical leads and other stakeholders around options for delivery
" HRH visit
" Review of evaluation framework
" First meeting of personal health and social care budget think tank
" Bringing together of VCSE and business investors to review options around SIBs, crowd funding;
includes Fifteen Cornwall, HSBC and VCSE groups