APMS Nursing Home (Lambeth)

Service Objective The Contractor shall provide high quality and safe medical care, which is responsive and tailored to the needs of patients and consistently available to all patients in Lambeth Nursing/Older people Homes as listed in Schedule 2, part 2 irrespective of the Nursing/Older people Homes in which they reside. Service Aims The Contractor understands that the aim of this service is to: (a) deliver a proactive patient centered model of integrated case management; (b) provide a responsive service which adapts over time to patient feedback and to changes in evidence concerning medical care for the Nursing Home resident; (c) provide clinical leadership to improve the overall quality of care for patients in Nursing/Older people Homes (d) develop effective working relationships with Nursing/Older people Homes , acute hospitals, South London and Maudsley, community services and other stakeholders which will allow the Contractor to effectively deliver against the objective of this service; (e) improve the quality of medical support to the patient (including acute responsiveness, proactive holistic care delivery as well as well as advance care and end of life planning and support) ; (f) improve patient satisfaction; (g) improve end of life care and deliver Gold Standard Framework for Nursing/Older people Homes (GSFCH) which should deliver fewer hospital admissions and less numbers of deaths in hospital. The commissioner will work with the Provider in Year 1 to finalise a baseline as part of the wider development plan to agree Year 2 plans. Therefore, the Contractor requires a range of clinical and social skills including discussing and recording 'do not attempt resuscitation orders' and advance care plans using the Urgent Care Plan (UCP) system with patients and their families in a culturally sensitive manner and recording any such agreement; (h) improve management of long term conditions, frailty and dementia and take leadership in the systematic review of all aspects of care including geriatric syndromes such as nutrition, continence, skin care and falls & osteoporosis risk identification, response and prevention); (i) improve the wellbeing of Nursing Home residents; (j) Improve medicines optimisation and reduce overprescribing of medicines and medical devices that patients don't need or want, or which may do them harm; supporting the national