This DES applies from 12 April 2017.
Aims of the DES
The aim of the DES is to enhance the care provided for residents in care homes through a proactive, coordinated model of care.
The DES seeks to delivered best-evidences treatment and services, maximise continuity of care, minimise unplanned transitions of care, minimise the risk of polypharmacy and ensure the most appropriate professional is available to deliver care.
£270 per care home resident for each financial year. Payment will be monthly or quarterly upon submission of a claim to the health board. Claims must be accompanied by a list of residents residing in the care home on the last day of the quarter.
If a resident resides in a care home for up to six months of the relevant year the practice receives 50% (£135) of the annual payment. If a resident resides in a care home up to 9 months of the relevant year the practice receives 75% (£202.50). If a resident resides in the care home for over nine months of the year the practice receives the full amount.
Initial resident review – each resident must have a comprehensive review of their mental and physical health within 28 days of moving into the care home, which will include a medicine review. A proforma template outlining areas for review is available in the DES specification (see below). A multiprofessional team approach to the review will be necessary.
Monitoring the provision of care – Monitoring care will include home visits or a virtual ward approach and integration with existing crisis response teams and care home staff.
Clinical review – Each patient who resides in the care home for the full financial year should have a minimum of one clinical review undertaken by the practice. Where appropriate a practice nurse or pharmacist will support the GP to undertake the review.
Medication review – A pharmacist will undertake at least one medication review during the year.
Annual resident review – Each resident must have a comprehensive annual review within four weeks of the anniversary of the day the resident moved into the care home.
Post unscheduled care review - this must be undertaken within 4 weeks of receipt of a discharge summary following attendance at A&E or emergency hospital admission The review should establish if the attendance could have been avoided and what further action could be taken to reduce the possibility of further unscheduled care.
Advance care planning – Special patient notes about vulnerable and palliative care residents must be provided to the out of hours service.
Annual report – Each practice or lead practice acting on behalf of the cluster should complete an annual report of outcomes by the 31 March each year. A proforma is included in the DES specification (see below).
A review of the DES will be undertaken six months after implementation.