Integrated Services. Dr Steve Cartwright Clinical Executive for Integration and Partnerships Andrew Hindle - Commissioning Manager for Integration

Transcription

1 Integrated Services Dr Steve Cartwright Clinical Executive for Integration and Partnerships Andrew Hindle - Commissioning Manager for Integration

2 Dudley CCG: context CCG registered population = 312, practices 10 single handed practices Mixture of wards including some in the lowest 20% for most deprived across the country and some in the top 20% of most affluent.

3

4 Dudley Health and Social Care Economy The Opportunity Unnecessary emergency admissions Too many admissions to nursing and residential care Recognition by partners of the need to address through a step by step change in service delivery Commitment to redesign urgent care Evidence that 5 day working creates dysfunctional service pressures

5 Integration and Better Care Fund 7 day services Integrated teams Community Rapid Response Team Dudley Care Home programme OD: Leadership programme Single point of access Prevention agenda and tele-health Risk stratification

6 7 day services Dudley was successful in applying to be one of the National Early Adopters Cross health economy working group set up Working with NHS Improving Quality Team Three main areas of focus Mapping of services Developing community standards Sharing best practice with other early adopters

7 7 Day Response To Avoid.. Post weekend peaks in admissions Postponement of discharges due to absence of support services therapy, pharmacy etc.. Unnecessary admissions due to absence of more appropriate primary and community health services Inconsistency of patient experience and response, 7 days per week

8 Heart failurejoint pathway with acute Community Mental Health Teams: adults and older people Palliative care team Care home nurse practitioners Stroke Community Respiratory Team District Nurses Dementia Gateways MH Crisis Resolution Current 7 day working Community Rapid Response Team Tele-care services Virtual ward (Case Managers) Intermediate Care OT Current 7 day working From July 2014 Potential to move to 7 days in 2014 Physio Neurology SLT Social service teams

9 Community Rapid Response Team Evidence base:- 19,500+ over 65 arrived at ED 14,500 admissions over 65 10,000+ over 75 6,500 admitted for 2 days or less 85% arrived by ambulance

10 Community Rapid Response Team Team of 9 Advanced Nurse Practitioners (ANP) Integrated with social care assistants and care home nurse practitioners ANPs take a referral or co-respond with West Midland Ambulance Services Assess, diagnose, initiate treatment, instigate social care package if required and refer to integrated teams

11 Community Rapid Response Team for Older People with Frailty Integrated with Care Home Nurse Practitioners and Social Care Assistants PATIENTS WMAS NHS 111 GP Out of Hours Single Point of Access for Advanced Nurse Practitioner Based at WMAS Community Nursing Teams Assessment by ANP or Care Home Nurse Practitioner Within one hour Admit to EAU - Initiate treatment - Initiate care package up to 7 days (then review) - Initiate care plan Step down to Locality Integrated Teams

12 Service Integration Practice integrated teams To consist of GP, pharmacists, community nurses, named social and mental heath workers. To review risk stratification tools and agree a Care Coordinator for complex cases GP Leadership posts in each locality

13 Infrastructure for integration A comprehensive organisation development programme A common Information Technology platform A common approach to care planning An agreed performance framework

14 Dudley Care Home Programme Over 2,200 residents in nursing and residential homes registered with a Dudley GP High number of urgent care admissions Dudley Care Home GP programme operates to provide proactive care and initiate advanced care plans. Team of 6 care home nurse practitioners to double in size to be integrated with rapid response team and become a 7 day service.

15 Single point of access Proposal is to have a Single Point of Access phone number for community health and social care services To include a fourth option where there is more than one problem/issue and requires triage. This will enable effective triage and the call handler takes on the role of a facilitator rather than navigator.

16 Prevention agenda Develop self care programmes Develop technology including remote monitoring tools (tele-health) Increase utilisation of voluntary sector (community link workers) Social prescribing

17 Palliative and end of life care Investment in palliative care services including a new palliative care consultant Practice identifying more people in their last year of life to ensure a multi-disciplinary team approach and support Increase and standardised approach to advanced care plans More people at end of life having choice of preferred place of care

18 Learning from patient experiences Patient perspectives addressed via the health economy Integrated Working Group Aim is to capture the actions and improvement that need to be implemented. Feedback given to the patient, carer or advocate that provided the story/experience.

19 Questions?

20 1. In your case study what elements of the service worked well? 2. What elements didn t work well? 3. What could have worked differently?