Joining up health and care: Your views and feedback. Greater Nottingham Transformation Partnership Thursday 10 May 2018

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1 Joining up health and care: Your views and feedback Greater Nottingham Transformation Partnership Thursday 10 May 2018

2 Welcome Kamaljeet Pentreath Patient Active Group

3 Housekeeping and objectives No fire alarm planned this afternoon Our format: Presentation followed by discussion, with time for questions at the end (programmes on your tables) Please be respectful, we all need time to have our say Objectives for the next two-and-a-half hours: To bring you up to date with what s happening in health and social care To discuss your views and experiences so we can feed back into our ongoing work To answer any questions you might have This is your forum. We ve created this time for you Forms on your tables to submit questions at any time

4 Who s here today Presenters: Dr Hugh Porter and Lyn Bacon Table facilitators: From the transformation programme, STP, CCGs, Citizens Advisory Group and local patient leaders Scribes: From across our partnership to record your feedback Patients and citizens: To give us your views and opinions We have the right people in the room to ask and answer questions, explain what s happening now and also to shape what s to come

5 Ground rules This is the third public event we ve held in Greater Nottingham The questions and answers from the first two events have been circulated and are on your tables The intention this afternoon is to keep moving the conversation forward Please be respectful in how you express your opinions Please remember: we re all working towards the same goal we want to make sure everyone gets the best care possible from a health and care system fit for the future We have an opportunity to build on the best practice we ve already established locally

6 Our journey to integration Dr Hugh Porter GP and clinical lead in Greater Nottingham Lyn Bacon Chief Executive of Nottingham CityCare Partnership

7 Our story so far 1. We have to change 2. It s not simply about pumping more money into the system 3. We believe we can join up all of the different NHS organisations and the social care delivered by local councils 4. Our local NHS has a history of innovation that we can build on 5. This will not change the fundamental principles of the NHS

8 Objectives shared by all of our organisations Clinical Commissioning Groups Pioneering work that sits underneath the Sustainability and Transformation Partnership (STP) The key aims are: 1. Improve health and wellbeing 2. Improve the care provided and the quality of services 3. Tackle the growing pressure on budgets

9 Quick overview of the last three years Phase 1 we compared our system to others internationally and decided there was value in working towards integrated health and social care Phase 2 We started to map and plan what this integration could look like Phase 3 Announced nationally as an accelerator site for integrated health and social care. We re currently putting in place the building blocks of what is needed to join-up Phase 4 options for moving forward to be considered later this summer This has all involved learning

10 Our learning for integration: three key elements Right care Right infrastructure Right system Population health management Standardised pathways Patient flow New models of cross organisational care IT and data Financial management on the whole population Transformation funding Integrated commissioning Provider partnership System integration i.e. ongoing management of integration functions and activities Workforce and Cultural Change

11 Element 1: Targeting care where most needed Complex and Very Complex Needs: Identifying patients early and putting steps in place to improve their care Emerging Needs: Proactively supporting people to stay healthy by giving experts the right tools and interventions Mainly Healthy: Engaging people, particularly those that are harder to reach, to remain healthy and access the right care in the right way. Very Complex e.g. end of life and continuing care Complex e.g. LTCs, cancer, social care support Emerging Need e.g. at risk children, mental health and development conditions Mainly Healthy e.g. generally healthy, healthy but with risk factors, missing preventive screening

12 Element 2: the right IT and data systems

13 Element 3: how the system could fit together Integrated Strategic Commissioner Greater Nottingham Providers Provider Alliance Integrated Care Provider Partnership GP Surgeries LA Provision Pharmacies Integration Capabilities and Resources Integration Support

14 Our landscape Nottingham North & East Four CCGs: - Nottingham City - Nottingham West - Nottingham North and East - Rushcliffe Two Local Authorities: Nottingham West Nottingham City Providers: Rushcliffe Other providers: - GPs - Pharmacies - Third Sector

15 Our challenges Health and wellbeing: Local healthy life expectancy is too low Care and quality: High mortality rates for patients with long-term conditions elderly and frail spend too much time in hospital flow in our urgent care pathway doesn t achieve the national access standard Health problems are diagnosed late often in crisis leading to avoidable hospital care and worse outcomes Affordability: Current funding gap projected to grow to 314m by 2020/21 unless we make radical changes Culture: Poor track record of delivering major whole system transformational change

16 Why change? Benefits for our citizens Prevention and proactive care Standardised pathways of care Integrated care provision Improved outcomes Benefits for our system More efficient, joined-up working Fewer barriers, less duplication = streamlined Meeting rising demand More cost-effective

17 Integrated Respiratory Service A unified approach across Community, Hospital and Ambulance Services Holistic support to people frequently admitted to hospital in crisis A single consistent approach to care Reduced length of stay in hospital 22.7% % Support within 2 hours of hospital discharge

18 Anne Lives alone in Nottingham aged 69 years 7 hospital admissions over 12 months in crisis with respiratory problems and severe anxiety Reviewed by a nurse working across hospital and community Holistic plan involving wider partners including Healthy Housing and IAPT services Supported Housing, integrated care plan In subsequent 12 months only one hospital admission

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22 Group discussion At your tables

23 What we mean by best practice care Previous events have looked at different elements of how we integrate care: 1 st event: We looked at what good quality care looks like and how we can better join up health and social care 2 nd event: We discussed how a new model of Population Health and Wellbeing can focus care based on categories of need Today: We re going to focus on our learning on the framework we believe we need to create to an integrated health and care system

24 Our framework for integration Right care Right infrastructure Right system Population health management Standardised pathways Patient flow New models of cross organisational care IT and data Financial management on the whole population Transformation funding Integrated commissioning Provider partnership System integration i.e. ongoing management of integration functions and activities Workforce and Cultural Change

25 Discussion for this afternoon The theme for the discussion is around the Best Practice Care workstreams that we see as part of the integration framework for our system These include: Population Health Management (covered in the last event) Standardised Pathways Patient Flow New Models of Cross Organisational Care At this event we will discuss (1) New Models of Cross Organisational Care and (2) Standardised Pathways as they have an impact on outcomes and patient experience.

26 Discussion topic 1 New models of cross organisational care Helen Griffiths, Workstream Lead

27 Principles Embed Home First mantra Discharge planning will always include patient/carer input Single point of access to support discharge to assess Therapy and social work teams collect information on how people managed at home before becoming acutely unwell People are discharged to their usual place of residence, with additional support if required and assessment of their longer term needs undertaken there rather than hospital. A clear clinical care plan is set for all patients within 14 hours of admission and within maximum of 48 hours, which includes an expected date and time of discharge Board rounds take place on all hospital wards each morning, reviewed by multidisciplinary team

28 Before the Integrated Discharge Team Multiple Teams Accountable for Patient Discharge A/E Discharge Unit Receives Patient Information Practively Through A/E alerts for those presented at Acute Hospital Specialty Receiving Unit (SRU) Discharge Unit Receives Patient Information Proactively Through SRU alerts for those presented at Acute Hospital Elective Admits Discharge Unit Receives Patient Information Proactively Through referral pathway for certain elective procedures scheduled Admission Clinicians in Special Front Door STOC Team Rounds (e.g. HCOP) diversion identify patients for discharge Clinician in Wards Identify patients for discharge. Various Pilots (e.g. IN REACH) identify patients for discharge Back Door Supportive Transfer of Care (STOC) 2 Person Team: Identify patient admits that require supported transfer out care out for discharge 200 patients medically fit for discharge daily. 160 out of 200 people require supportive discharge Simple Discharge: Does not require supported transfer of care. Repatriation Discharge: Patient may need to be discharged back to another facility (e.g. acute hospital). Early Supported Discharge for special groups, e.g. Stroke Unit by CityCare Continuing Healthcare: Patient requires Continuing Health Care Services (with primary health need). Fast Track: Patient requires Continuing Health Care Services and has a terminal conditions. Transfer to Assess Patient may transfer patient to a lower level setting bed (intermediate care), but requires assessment. Identified Re-ablement. Patient requires short term, intensive support when a patient is discharged from hospital. Its objective is to help people to recover as quickly as possible from an acute illness and regain their independence to reduce the likelihood of admissions to hospital or long term care. Discharge to Assess: Patient may have long term social care need. Patient is discharged to home for assessment by social care worker. Discharge City - Health and Social Care Hub County Rushcliffe Hub County N/E Hub County West Hub County Social Care City Patients Intermediate Care at Home Connect (13 beds) Clifton View (28 beds) Wollaton Park (16 beds) Lings Bar (Nursing Rehabilitation, 72 beds) - only one accessible on weekends County Patients Connect House (Continuing Health, 22 beds) Lings Bar (Nursing Rehabilitation, 72 beds) - only one accessible on weekends The Grand (Resi- Rehab, 23 beds) Leivers Court (15 beds)

29 Urgent Care and A/E Diversion After the Integrated Discharge Team Integrated Discharge Unit: One Team Accountable for Discharge Pathway in Hospital A/E Admission Discharge Discharge Unit Receives Patient Simple No supportive transfer of care needed Simple Discharge (requires no coordination of health and social post acute) Specialty Receiving Unit (SRU) Discharge Unit Receives Patient Information Acute Ward Supported Discharge All in-patients requiring new or increased support to leave hospital acute care. Managed by the Integrated discharge team - a virtual team that will provide 1 single point of referral to case manage discharges from the acute setting within 24 hours of medically safe Pathway 1 Patient needs can be safely met at home Elective Admits Discharge Unit Receives Patient Information Pathway 2 Patient requires further reablement/assessm ent in community facility (Sub-acute reablement) Pathway 3 Patient has complex ongoing care needs (Sub-acute assessment)

30 New Models of Cross Organisational Care Table discussion 1. What is your experience of care (for yourself or someone you know) when multiple organisations are involved? 2. Did you see ways that different organisations were working well together? Were there any problems? 3. How can we improve the patient and carer experience when multiple organisations are involved?

31 Discussion topic 2 Standardised Pathways Dr Hugh Porter

32 Standardised Pathways: Background A patient pathway is the route that a patient will take from their first contact with an NHS member of staff (usually their GP), through referral, to the completion of their treatment. It also covers the period from entry into a hospital or a Treatment Centre, until the patient leaves. The ambition is to develop standardised pathways that identify the best practice to be followed in the treatment of a patient or client with a particular condition or with particular needs.

33 Standardised Pathways: Background A standardised pathway will: Be a distillation of the best available expert opinion on the care process and should be evidence based. Identify the most appropriate setting of care for each stage of the pathway (enhanced community based services, access to specialist pinion, hospital care, etc) Be clear on expected outcomes and measurement of quality at all stages of the pathway Recognise that there will be times when the pathway is not appropriate for an individual one size does not fit all

34 Standardised Pathways: Table discussion 1. What would make you feel confident that your GP is making the most-informed, consistent decision about referring your care or the care of someone you know? 2. How involved do you feel in decision making when your care or the care of someone you know moves on from your GP to other people in other organisations? 3. How can we better map/explain these pathways to patients and carers? What information should be made available to you as a patient about your pathway?

35 Questions From the floor

36 Reminder: Ground rules The questions and answers from the first event have been circulated and are on your tables The intention tonight is to keep moving the conversation forward Please be respectful in how you express your opinions

37 Closing remarks Kamaljeet Pentreath Patient Active Group

38 Closing remarks Observations from this afternoon Feedback forms on your tables Please keep an eye on our website for updates

39 Thank you