Community Health Services · UK public procurement notice

Services which will need to be delivered as part of the contract

1. Hounslow Falls Prevention Service

The aim of the service is delivery of a whole system and community coordinated approach to preventing falls through partnership working using existing skills knowledge and expertise to solve problems and realise opportunities. At the core of this Service is a clinically led, referral based intervention service, supported by a wider information and advice offer.

This will be achieved by:

effective joint working and coordination of partners who contribute to supporting older people in the community and promoting independence

Early and effective assessment

Training and supporting care providers

Provide proactive follow up of those who are assessed as requiring Falls Prevention intervention at 12 weeks and 6 months to ensure that individuals’ gains made are maintained

To support Hounslow residents the new service will have integrated community and clinical pathways.

Clinical

Provide access to timely screening and follow-up assessments in the community (including in primary health care settings/teams and other community access points) using a common validated brief assessment tool.

Consist of a community-based team that will work with the hospital based clinical falls service.

Provide access to specific falls prevention exercise programmes

PCN (Primary Care Network) will be aligned with service provision delivered through a community-based team providing occupational therapy, physiotherapy, and nurse services to clients aged 65 years + who are at risk of falling

Community

Provide a range of information about how to access support in Hounslow including steps residents can take for self-management to reduce their risk of a fall.

Establish systems and processes for voluntary and community sector to identify people at risk of falling and refer them into the falls assessment pathway.

Provide residents with access to home safety/hazard self-assessments that allows for self referral

The service will accept self-referrals and referrals from relatives, GPs, care home staff, community nurses, hospital staff and social workers for adults over the age of 65, living in Hounslow – referrals will only be accepted for those within the defined ‘at risk / over 65s’ cohort. Interventions and support will be time limited

KPIs

Number of falls related emergency hospital admissions in cases over 65 and under 80

Where falls occur, and a profile of residents who fall, age, gender, ethnicity, activity levels, where they live, pre-exiting co-morbidities

Numbers of repeat falls (with/ without acute admission) within 1 year (April to March)

Number of falls identified within care setting (assessed frailty resulting in prevention intervention) Number of hip/ other fractures sustained due to a fall

Number of frailty assessments undertaken that lead to referral to a Falls Prevention service

Audit quality of assessments, quality of referrals, follow up assessments at 12 weeks and 6 months to determine sustained improvements

2. CVD Prevention (Healthy Hounslow)

Healthy Hounslow is an Alliance of four providers who deliver the borough’s integrated health and wellbeing service via four ‘Lots’. The aim of the Lot 4 CVD Prevention service is an early intervention, detection, and prevention service in the community.

CVD Outreach

The service will deliver CVD outreach in the community including education, awareness, and 1,000 blood pressure readings annually.

A clinical pathway will be developed for high/low blood pressure readings.

Community NHS Health Checks (CNHSHC)

The service will be required to provide 500 targeted outreach CNHSHC per year, at a minimum of 3 outreach clinics per week.

The service will target areas of higher deprivation, the routine and manual workforce, and residents with a higher risk of developing CVD, diabetes, and other long-term conditions.

CNHSHC will be offered to those who live, work, study and/or are registered with a Hounslow GP aged 25 to 74 years old, providing they do not meet any of the exclusion criteria set out in the NHS Health Check Best Practice Guidance.

The service will offer CNHSHC at varying times, including outside working hours and weekends, to maximise access.

The provider is expected to adhere to all associated quality measures, clinical governance and information governance requirements, including NHS Health Check Best Practice Guidance.

The provider will source and maintain stock levels of equipment for CNHSHC. The cost of consumables must be met within the contract value.

CVD Health Coaching

The service will offer CVD Health Coaching to residents who are identified to have any of the following risk factors: smoking, lack of physical activity, obesity, or Q-risk ≥ 10%.

CVD Health Coaches will offer up to 6x 1-1 sessions over no more than three months (including how to manage risk, and lifestyle behaviour change information and support).

Sessions will be tailored to the service user’s requirements and will involve motivational interviewing and goal setting.

Sessions will be arranged at a time and location suitable for the client. Virtual and/or face-to-face options will be available.

Outreach activities and events will be held in locations suitable for recruiting target populations, including but not limited to faith settings, supermarkets, workplaces, leisure centres, and community events.

The oversight for the clinical governance of the CNHSHC will come under the BBP CVD group.

Key performance indicators

500 CNHSHC annually. Report the proportion of relevant risk factors e.g. high BMI, high BP

Additional 1000 blood pressure readings annually in the community. Breakdown of results (categorised low/normal/elevated/high)

80% of all eligible patients referred to lifestyle interventions programmes, signposted to other support or declined either

Record breakdown by community venue/workplace

Record breakdown by gender, age, ethnicity, GP Practice, postcode, priority groups

Record number o…