Delivering Joined-up Care. The Torbay Experience

Transcription

1 Presentation Background Person centred approach Mrs Smith Vision Service Model & Operational Characteristics Changing cultures between H&SC Leadership across the whole system of care Communication Strategy Measurement & Evidence

2 Delivering Joined-up Care The Torbay Experience Mandy Seymour Chief Executive Torbay and South Devon Health & Care NHS Trust April 2013

3 About Torbay Population of c320,000 Centred around 10 localities in Torbay and Southern Devon Majority of acute patient flows to local DGH South Devon Health Care Trust 37 GP practices 25.2% of Population over 65 years old 8% of Population over 75 years old 4% of Population over 85 years old One Clinical Commissioner for NHS

4 Brief History Torbay Care Trust created December 05. Pilot year 04/05 The PCT was a stable and successful delivering financial surplus and excellent performance History of partnership working Consistency of the senior leaders in the health community. Poor performing Adult Social Care Service One star performing organisation PCT - Kaiser Beacon Site since 2003 culture of collaboration

5 What people told us... Improved access Single Point of Contact Responsive services Wanted to tell their story only once Wanted the people who saw them to talk to each other

6 Social Worker Practice Nurse G.P. District Nurse O.T. Diabetologi st Cardiologist

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8 Person-centred approach Mrs. Smith vision Clear and simple message Use of patient stories Understanding what added value to Mrs. Smith Engagement of front line teams Clear Objectives

9 Key Objectives Improving access timeliness and information Eliminating buck-passing Simplifying decision-making Increasing efficiency Shortening time from identification of need to service delivery Reducing communication failure

10 Community Service Model 10 Zone Teams defined by GP Practice populations (25k-45k population) Single Point of Contact General management/professional leadership Co-located Multi-Disciplinary Teams Health and Social Care Coordinators Making the right thing to do the easiest thing to do. Intermediate Care 7 days pw/evenings

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12 Operational Characteristics Single community H&SC record Single Manager with a pooled H&SC budget Decision making moved to the front line Performance focus shared with front line Access to GP records in the Zone H&SC Coordinators on 8 Acute Wards Access to community info on acute wards Yellow Folders for most vulnerable

13 For example, from this 7 stage process GP/District Nurse Social Services Referral Coordinator Service Manager Care Manager Service Manager To this 2 stage process Home Care Manager Broker GP/District Nurse HSCC Broker

14 Health & Social Care Coordinator Role Focal point of referrals to zone team Coordinating response and building relationships Dealing with public and local professionals Ability to set up packages of care Refer complex cases to MDT Seen as significant improvement to GPs Access to hospital systems and some GP systems

15 Clinical Leadership Clinical Cabinet Medical Directors, GPs, Senior Managers Sets out strategic vision for our System of Care Clinical Commissioning Group Strategic Design Groups LTC/MH/Elective/Emergency Admissions Clinical Pathway Groups Speciality Specific Clinical Advisory Group Local GPs and Multi disciplinary Professional Forum driving Quality and Safety

16 Bed Day Usage per 1,000 pop Resulting from Emergency Admissions, patients aged 65 and over Bed days per 1000 population Torbay South West Region

17 South West PCTs Bed Day Usage per 1,000 pop Highest 1281 Devon 977 Torbay 704

18 Impact Minimal delayed discharges from local DGH & fewest excess bed days in south west Lowest non-elective LOS in the southwest & 4th lowest in the country Lowest occupied bed days for >75s patients with 2+ admissions Acute beds reduced from 750 in 1998/99 to 493 in 2010/11 Lowest rate of hospital deaths of any local authority in England at 44.60% - national figure of 58% I/C Access: 25% seen within 3½ hours; further 65% within 5 days. Rapid Equipment Service average 62 mins. Res & nursing home long stay placements reduced by 403 since Feb 06 from 1,298 to 895

19 Our challenge As health care providers To make the right thing to do the easiest thing do

20 Thank you for listening