Quality and Outcomes Framework guidance for GMS contract Wales 2016/17. Annex 3 Cluster Network Action Plan Western Vale Cluster

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1 nnex 3 Cluster Network ction Plan Western Vale Cluster 1

2 Strategic im 1: To understand the needs of the population served by the Cluster Network No Objective Key partners Improve uptake of vaccines for Western Vale Increase flu immunisation up take in at risk groups Improve alcohol awareness The Vale is the area of C&V with the highest LL/Public Health LL/Public Health LL/Public Health For comple tion by: - Dec 16 Dec 16 Mar 17 Outcome for patients Progress to date ating Sep 2015 Improve immunisation in all groups especially in those children after the first year of life Improve immunisation and reduce risk of flu in all age / risk categories educe alcohol intake by improving awareness/education regarding alcohol abuse Immunisation uptake at 1 year old is 95.7% (UHB is 95%) Immunisation uptake at 4 years old is 84.7% (UHB is 87.9%) Seasonal flu uptake of >65 years is 70.1% (UHB is 68.9%) Seasonal flu uptake of the at risk group is 46.8% (UHB is 48.2%) greed specific areas to target chieved highest uptake of 76% of flu in over 65s chieved high uptake of 59% in under 65s at risk Investment of Cluster Money into flu nurse for housebound excluded by DNs flu vaccination programme Cluster pharmacist to be trained to administer flu vaccination Nurse led CPET training on MECC completed DS self and P referrals working well 2

3 intake of alcohol in Wales Health Promotion. To increase engagement in the Smoking pathway by all practices. Improve access to Primary Care Mental Health Service Improve healthcare provision to housebound elderly LL/ Smoking Cessation Provider Mar 17 educe smoking SSW service removed in Cowbridge due to staffing issues has not been replaced ood cross cluster referrals made from surgeries to most local based service Practices using referral to SSW. LL/CMHT Mar 17 Improve access To invite CMHT to locality/cluster CPET for open discussion about access issues C&V wide issues due to resource/funding im to have clear list for suitable referral pathways for each patient LL/PH MCIST/U HB Dec 16 Improve healthcare provision to housebound elderly Safer prescribing for the elderly and reduce iatrogenic injury Investment of cluster money into Cluster Pharmacist to visit these patients and conduct appropriate pharmacy reviews Cluster money also to be used to enable Ps to conduct more comprehensive reviews aise awareness and of third sector services LL/ TENOVUS Ongoing wareness and access to third sector services Engagement with Tenovus and visit by Well Man Van continues to visit and good patient access 3

4 To immunise target groups for Men CWY in place of Men C LL/SCHO OLS Ongoing To prioritise immunisation of Men CWY in place of Men C for university entrants aged Production of joint note of invitation targeted at school leavers going to university to contact their local P surgery for Men CWY in place of Men C vaccination completed in 2015 Practices to consider auditing uptake of this vaccination over this period to present at a future cluster meeting To improve access to optometry services To improve patients attendance at all screening programmes CD Jan 16 To establish links with the optometry service locally and to improve access LL/ Public Health Ongoing To access up to date data regarding cluster patient attendance and to encourage patients to increase these levels Need to improve contact between the opticians, ophthalmology services and Primary Care to link in with teams via CD forum for updates screening = 81.9% (target 80%) Bowel screening = 55.4% (target 60%) Breast screening = 74.8% (target 70%) Cervical screening = 82.5% (target 80%) Discussions ongoing with Bowel Screening Wales to see how the cluster could best promote patients to attend this screening 4

5 To ensure patients have a low risk of falls ll/ Public Health/ CF Ongoing 66/1000 people in C+V will fall and subsequently attend the +E department each year In Western Vale there were on average 27 admissions with a diagnosis of hip fracture after falling Falls isk ssessments should be carried out on older patient reviews cluster funding to enable Ps more time to carry out better quality reviews on this group of patients Cluster funding also to be used to support the Cowbridge First esponders in their current new training to attend the uninjured fallers 5

6 Strategic im 2: To ensure the sustainability of core P services and access arrangements that meet the reasonable needs of local patients No Objective Key partners For comple tion by: - Outcome for patients Progress to date ating Improve ccess LL Ongoing Improve access to MS eviewed practice boundaries. Obtained practice maps of registered patients Contacted patients who are out of area regarding on-going management and agreed Dr to Dr handover of these patients Triaged requests for home visits eported number of house visits for past 3 years Increase availability of clinical appointments LL Dec 16 Improve access to MS Cluster decided against completing a Primary Care Foundation survey but will use cluster funding money to support cover for the Ps to access more patients 6

7 Succession Planning for Ps Eryl 2017 Improve access to MS Eryl surgery will be looking to replace a 6 session P in 2017 ppropriate nursing service provision LL/ Phleb / Wound care nurse Nov 16 To look at where practice nurse time is used inappropriately Discussions ongoing with the clinical phlebotomy service to pilot a more cluster focused service Working with the DNs/VCS teams to look at non MS work covered by the practice nurses To review best practice for ear syringing vs microsuction To audit the demand for preaudiological assessment in practice caused by the delay in ENT waiting times ccess to Ps PH Dec 16 Increase number of Dr appointments Use of cluster funding to support Ps to work more efficiently and to target harder to reach patients pplication for a cluster based winter pressures P cover to enable practice Ps to be removed from routine care and to work on those patients deemed to 7

8 be more complex or those demanding a higher level of MDT working Improve discharge information LL/ CD/ UHB/ BMU Ongoing Improve patient care egular crossborder meetings with BMU to discuss issues with patients who are discharged by an alternative LHB Ongoing discussions with Sharon Hopkins re: making better links with secondary care and reducing wasteful admin Planning for increased population LL Ongoing ccess to MS Planning for potential increase in patients and impact on existing services Highlighted to UBH that planning approval for housing in St than area had been insitu since 1980s therefore it was difficult to plan future service provision 8

9 Strategic im 3: Planned Care- to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms No Objective Key partner s Improve communication with District Nurses and re-delivery of INs LL For comple tion by: - Outcome for patients Progress to date ating Ongoing Improve availability for housebound patients to access phlebotomy / DN services overall e-instate PMS LL Ongoing Provision of PMS service Improve Family Planning Services Improve Hypertension management LL Ongoing ccess to Family Planning EP Mar 17 Improve Hypertension Management eview of district nursing and phlebotomy services across all 3 practices Expressed the need for better face to face communication with DN/VCS teams to improve overall patient care There is no longer a PMs service for Western Vale ll referrals to be sent directly to usual Mental Health Team Discussions with CMHT / third sector teams to improve patient access to these services Original Family Planning Services stopped in the cluster and now reinstated with less capacity Training for Ps to provide inhouse/cross cluster cover for these services Developed and implemented a new protocol for management of 9

10 educe antibiotic prescribing LL Nov 16 Improve effectiveness of antibiotics patients with hypertension Cluster Pharmacist to target this area Cluster/Practice and individual prescriber information to be distributed at prescribing visits European ntibiotic wareness Week starting 14 th November 2016 Practices to have at least one ntibiotic Champion to promote good prescribing to staff and patients practice organised promotional events egular pharmacist attendance and feedback at Cluster Meetings Improve Diabetic Care LL Ongoing Improve management of diabetes Specialist Diabetic Consultant (Julia Platt) has links with Western Vale and provides a quarterly 2 hour virtual DM clinic Use of the pacesetter pathways to improve in-house patient care Highlighted lack of specialist nurses and consultants across the three practices 10

11 Use of pathfinder / pacesetter scheme LL Mar 17 Improve the care of patients with chronic health problems To contact Julia to get practiced based information regarding patient Hb1C levels Continued using QP pathways from previous year UHB to provide information as to how the use of these pathways will be audited, monitored and renumerated Improve management for patients with trial Fibrillation Improve access to CMHS service Some pacesetter patient information leaflets not felt to be sufficient or appropriate to all patients to link with CD forum to discuss this LL Mar 17 Improve Care Strengthen links with anticoagulation management. re part of the F pilot run by Dr likhan Use of cluster money to enable Ps to be involved in this new service LL Ongoing Improve CMHS service This was highlighted to the LMC. Sought clarity from CMHS regarding boundaries as some 11

12 referrals were returned by CMHS in error. equested updated map of referral route for patients of the Western Vale Smooth transition of the MH health service from BMU to C&VUHB and continue to work with the CMHT as the service evolves in the Western Vale To provide a phlebotomy service at branch surgeries To improve access to minor surgery LL Sep 16 Improve access to CMHT service LL/ UHB Oct 16 To provide local access to a phlebotomy service LL Sep 16 To improve access to local minor surgery service Several meetings arranged and ongoing to ensure the smooth transition for our patients during the shift from the provision of secondary care CMHT from BMU to C&V UHB. Ongoing meetings with the Phlebotomy service to pilot a cluster based service to utilise better the system already in place ll three practices are providing access to joint injections Two practices offer minor surgery Cross practice referral system available To improve access to dermatology LL Sep 16 To improve access to dermatology Telederm referrals with camera access now in place and being used by all three practices To improve access to paediatric services LL Ongoing To improve access to paediatric services eviewed and discussed 12

13 paediatric referral data To improve access to ENT services EP Mar 17 To improve access to ENT services scertained that audiology referrals are included in the figures provided Issues raised regarding non MS work such as ear syringing being done by practices and secondary care unreasonable waiting lists and then extra demands on the Ps/nurse ENT are aiming to set up community clinics such as the one running in Barry practices keen to be involved in any work done in this area To implement Enhanced Services for NOCs To improve patient access to services To improve patient access to the Welsh mbulance Service Team UHB Mar 16 Offer patient choice for management of anticoagulation LL Mar 17 To improve patient referral and subsequent LL / WST Mar 17 access to services greed to apply for enhanced service subject to acceptable renumberation Investment of Cluster Money in new cluster wide referral management system The cluster will work with WST to develop a cluster paramedic pilot idea Working also with the Cowbridge 13

14 First esponders Team (volunteers) to promote their work and to support them with cluster funding 14

15 Strategic im 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous development of services to improve patient experience, coordination of care and the effectiveness of risk management No Objective Key partners To reduce un-necessary re-admission of patients with complex medical and social problems For comple tion by: - Outcome for patients Progress to date ating LL Ongoing To improve patient care Communicated with secondary care about safe and effective discharge from hospital particularly with respect to the quality of discharge notification and planning. lso to decrease unreasonable expectation of delivery of certain services by the practices. Cluster requesting links with the Wellbeing Co-ordinators when their work is distributed wider than initial pilot project Working with new VCS teams To improve local management of diabetic patients LL Mar 17 To improve diabetic services To ensure Specialist Diabetic Consultant and Nurses can be offered to all practices equitably To reduce &E LL Dec 16 To reduce &E Practices to audit data when 15

16 attendances attendances available to practices To reduce variance across the cluster in readmissions To reduce frequent attendances at Out of House services LL Dec 16 To reduce medical admissions LL Ongoing To reduce Out of House attendances Practices to audit data when available to practices eview of frequent flyer contacts and shared learning at cluster level Working with the Wellbeing Coordinators when available to target these patients To improve patient care LL Ongoing To improve patient care Ongoing practice involvement to To reduce iatrogenic injury and iatrogenic admission and risk management To improve Community access to cardiac defibrillators LL Ongoing To improve patient care and reduce risk of inappropriate admission CF Mar 17 To improve access to emergency care in the community improve patient care in all areas Cluster Pharmacist to target this area Cluster funding to be used to provide new/updated community cardiac defibrillators around the cluster and to enable the CFs to educate the community on how to use them 16

17 Strategic im 5: Improving the delivery of end of life care No Objective Key partner s Improve communication Ensure needs of patients in Nursing Homes are met Identify needs of patients LL/ DNS/M IE UIE For comple tion by: - Outcome for patients Progress to date ating Mar 17 Continuity of Care Focussed on continuity of care for palliative patients by including DNs from both Cowbridge and Barry based teams to bi-monthly Palliative Care Meetings LL Mar 17 PC needs identified Targeted Milsom House for recording on PC LL Mar 17 PC needs identified Targeted patients on Dementia on Dementia register register for recording on PC Improve shared learning LV Mar 17 Improve shared learning Highlighted to UHB that in many instances practices do not receive from Princess of Wales Hospital the cause of death. Improve shared learning LV Mar 17 Improve shared learning Highlighted to UHB that there is no feedback from Coroners. Improve communication LV Mar 17 Continuity of Care Highlighted to UHB that there is no acknowledgment from OOH regarding PC patient information that has been faxed ie lack of confirmation of receipt Improve communication LV Mar 17 Identification of specific needs Highlighted to UHB that more support from hospital is required for identifying patients who are 17

18 receiving palliative care and therefore would be appropriate for entry onto PC eg COPD and Heart Failure patients Improve Communication LL Dec 17 Continuity of Care Introduced weekly reminder system for alerting OOH Improve delivery of end of life care to patients with a non-cancer diagnosis Improve patient care and identify alternative local respite care provision LL Dec 17 Improve patient care Highlighted that patients on other chronic disease registers may need to be placed on PC LV Dec 17 Improve patient care Highlighted loss of respite care provided by Holme Towers 18

19 Strategic im 6 : Targeting the prevention and early detection of cancers No Objective Key partner s Urgent eferral and treatment For comple tion by: - LL Mar 17 Urgent access to treatment Outcome for patients Progress to date ating Prioritise need for practice based system for managing urgent referrals Urgent access to investigations LL Mar 17 Urgent access to investigations aised awareness for ensuring patient understands the reason why urgent investigations are required to ensure they attend appointments Urgent access to investigations Clarity regarding referral criteria LL Ongoing Urgent access to investigations LL/ CE Ongoing Clarity regarding access to referral To ensure patients contact P for the results of these investigations to reduce delay in onwards referrals where appropriate greed to promote private referral for urgent cancer investigations as patients are seen very quickly Highlight concerns regarding red starred patients who are downgraded and not felt to be seen appropriately backed up with audit data where available Improve communication ll Ongoing Shared Learning Feedback of instances where screening systems have failed at cluster and UHB levels where appropriate 19

20 Improve patient access to investigations LV Dec 16 Improve patient access to investigations Highlighted that investigations do not happen quickly enough hence some patients are admitted to hospital and diagnosis of cancer is only made at that point 20

21 Strategic im 7: Minimising the risk of poly-pharmacy No Objective Key partner s For comple tion by: - Medication Compliance LL Mar 17 Patient Safety Improved Healthcare Outcome for patients Progress to date ating educe multiple medication where possible Cluster Pharmacist to review complex polypharmacy patients Medication Compliance LL Mar 17 Patient Safety Improved Healthcare Medication Compliance LL Mar 17 Patient Safety Improved Healthcare Medication Compliance LL Mar 17 Patient Safety Improved Healthcare Targeting patients in nursing homes for polypharmacy reviews Targeted elderly patients requesting home visits for polypharmacy reviews Cluster money to be used to enable Ps to do these reviews more easily greed to highlight requests from Psychiatrists where patients are discharged on specialist initiated medication accompanied by a request for the Ps to provide repeat prescriptions without a treatment plan 21

22 Strategic im 8: Deliver consistent, effective systems of Clinical overnance No Objective Key partners Improve Clinical overnance For comple tion by: - Outcome for patients Progress to date ating LL Mar 17 Patient Safety Practices to update the Clinical overnance Practice Self ssessment Toolkit (CPST) and to confirm completion and submission to the LHB by March

23 Strategic im 9: Other Locality issues No Objective Key partners For comple tion by: - Outcome for patients Progress to date ating Improve patient care UHB Ongoing Improved patient care Highlight that majority of patients attend POW hospital and therefore need UHB to develop relationship with this provider Ongoing cross border meetings with Locality Director and Community Director to raise these issues and to work together to resolve them 23