New Models of Care Jeannie Harrop Senior Commissioning Manager NHS Blackpool CCG Michelle Ashton Senior Commissioning Manager NHS Blackpool CCG
New Models of Care Coordinated and integrated support for patientswithat least two complex conditions Coordinated and integrated support for patients with complexconditions or other factors impacting health and wellbeing Care for patients with minorhealth issues, if any Extensive Care Enhanced Primary Care Episodic Care Multiple complex condition s 2-3% Complex conditions 35% Minor health issues upto100%
What do they provide? Large teams of staff comprising of:- Team Leader Community nursing Community matrons Rehabilitation therapists (OT and physio) Clinical care coordinators Health and Wellbeing Workers Neighbourhood assistants Refer to other services Education and training Step up /step down provision to Extensive care Covering areas such as:- Chronic Disease Management reviews Heart failure Diabetes COPD Falls End of life care (EPaCCS) flu injections Monthly neighbourhood and Multi Disciplinary Team meetings Re-referral / follow ups General advice i.e. nutrition and hydration equipment
Enhanced Primary Care 2017/18 Drug and alcohol services services aligned with neighbourhoods. Mental health specialist staff will work with neighbourhoods. Social Care social worker to be co-located in the hubs; longer blocks of care / more hands to support EMI / dementia / challenging behaviour at home; care available at the point of need on a short term basis similar to Rapid Response model; Enhanced rapid clean service to enable discharge / avoid ambulance conveyance to A&E Other services will also link to the neighbourhoods including the Police, Fire Service, and eventually all community health services. Currently under development hospital discharge processes into the hubs and self referrals
Empowering People and Communities Key focus for 2017/18 year. One of 15 areas receiving intensive support from NHS England. Already implemented Patient Activation Measure locally in our Extensive Care service and continuing to roll-out further. Completed in Central West Just starting in Far North and South
Blackpool Care Home model Evaluation of the pilot. Model to be integrated into neighbourhood hubs. Roll out planned across Blackpool from December. Fair share allocation being discussed / agreed at neighbourhood meetings. To provide planned regular reviews for patients with long term conditions or who are end of life To provide a responsive service for urgent patient issues either by phone, visits or via care home connect All phones calls from care homes will be via the hubs, not to primary care, who are responsible for signposting or triage. Care home connect 6
End of Life Care Updated Fylde Coast strategy EoLC pathways to work closely with the neighbourhoods care homes Trinity CNS team GSF meeting EPaCCS Review of DNACPR form Keeping people in their preferred place of care
Patient Stories The district nursing team visited a gentleman with a nephrostomy tube on alternate days to manage a wound to a supra pubic catheter site. The gentleman also attends the hospital weekly for specialist support in changing of the nephrostomy site dressing. It became increasingly difficult for the patient to attend this and so the team are liaising with the specialist out-patient department for support and training for a number of staff so that they can then redress the nephrostomy at home. This is resulting in better care for the patient closer to home, reducing duplication, a reduction in out-patient appointments and a reduction in hospital transport costs. We have a complex diabetic patient who has District Nurse visiting 3 times a day to support and prompt with administering insulin with our integrated team this lady has been under the umbrella of a number of the team to date to support her. She has involvement with the health and well-being worker to help her make healthier food choices and has supported her going shopping, Community matron has been managing her long term conditions and OT for rehabilitation needs. This integrated approach has reduced her calls to the ambulance service and reduced the number of times she contacts primary care
Patient stories Lady with several long-term conditions who had moved from South of England to live with her family in Blackpool. In her previous setting she was seen by the community nurses for chronic leg ulcers for over 10 years, had poor medication compliance and understanding of her condition, poor mobility and was socially isolated virtually housebound. On admission to the North neighbourhood team, a plan was developed in collaboration with patient and her family not only to manage her leg ulcers but to manage her long-term conditions. The patient was seen by the neighbourhood team, assessed and an integrated plan was implemented. Patient was discussed in team daily handover so all team members (nursing and therapy and matron) were aware of ongoing plan and progress. After 6 months of intensive treatment and therapy, patient s chronic leg ulcers have healed and the patient now has excellent medication compliance. Patient is now able to safely mobilise within her surroundings and is able to get out weekly to a Day Centre improving overall well-being and she no longer feels so isolated.
Patient stories Complex terminal patient who receives daily support visits from the District Nursing team. After review the patient is now seeing the Health and wellbeing worker who is not only trying to manage her ill health and poor prognosis but also come to terms with mental health issues. She has asked if our health and well-being staff member will help her and her family start to make plans for her funeral and signpost her to financial support she may be able to access also through the local council. Bariatric patient who is currently receiving daily visits from the DN team for weeping, venous ulcers to her left leg. The lady has a fear of leaving the house and attending hospital appointments. The health and well-being worker has been helping this lady to start to look at her weight issues and signpost her for help. She needed to see the vascular consultant a few weeks ago and he along with the family supported her in attending the hospital to the appointment. Her care is being coordinated closely so the health and wellbeing staff member visits who is able to carry out the wound care required on that visit also so eliminating duplication of staff.
Patient Stories An example of collaborative working is our Occupational therapist (OT) is now an integral part of the team and handover. It was identified that a newly diagnosed palliative patient required assessment and support with equipment at home. Our OT and nurse were able to plan an urgent visit the following day to support the patient and provide equipment and support in a timely manner. When our Health and Well-being worker (H&WBB) started we had just had a patient who passed away and at our initial bereavement visit her husband was struggling to come to terms with her death and was not taking care of himself. H&WBW visited and helped him gain confidence and supported him to access the bereavement service in the third sector, which he is attending and responding well to. The gentleman is also now supporting his brother in law deal with his wife s death and is a great advocate for bereavement support.
Doris was an 89 year old lady who resides in a Residential Care Home. Doris has a diagnosis of Dementia. Doris had been seen by the Care Home Support Team at the start of the week where she was given a full assessment and after discussion with her GP commenced on antibiotics for cellulitis to her right arm and leg. As the week progressed, she was reviewed and the Care Home staff noticed there was little improvement in the cellulitis and they reported that Doris behaviour was out of character. It was also felt that the cellulitis was deteriorating. In order to rule out an admission to Hospital it was felt that a reassessment of Doris by the Care Home Support Team and then to make a decision as to whether or not we felt that Doris needed to be admitted to hospital. The ideal for Doris would be to continue with an oral antibiotic in order to keep her in the environment that she was accustomed to as she would be unlikely to tolerate an intravenous line. She was visited and her B/P, respirations, heart rate,spo2 and temperature were all taken and were found to be within the normal range. She also did not present as systemically unwell. The readings were reported back to the GP who felt that it was more appropriate to treat Doris within the Care Home environment. An alternative antibiotic was prescribed after discussion. Worsening advice was given to Care Home staff by the Care Home Support team and support mechanisms to ask for help over the weekend, should things deteriorate. This stopped an unnecessary GP visit and a potential hospital admission over the weekend.
Patient Stories Health and Wellbeing Support Worker referral received from GP for anxiety support. On completion of initial assessment, it was identified that the patient needed support from Occupational therapist (OT). On return to office 10 minute brief discussion with OT regarding assessment and what was identified with the patient to maximise her independence in the home. OT agreed intervention and support from OT would be beneficially for this patient. Electronic shared record with OT. OT completed their assessments within 3 weeks of problem identified. Discussion with Assistant Practitioner (AP) regarding a patient she had been to see to complete weight and bloods. Whilst the AP was completing her home visit, the patient expressed concerns regarding her poor mobility and low mood due to her weight. AP had brief discussion with the patient regarding the new Health and Wellbeing Support Worker role and what support could be offered. Patient agreed this would be helpful. Verbal discussion between the two regarding this lady electronic referral completed. Initial assessment completed and the patient has identified aims/goals she would like to achieve. Patient is working towards losing weight with the community eat well service and is aiming to be back in her old dresses by summer.
Patient Stories Patient was known to the Occupational therapy (OT) service and was visited due to concerns over neck collar causing pressure issues. OT noted a significant deterioration in the patient s condition, when discussed with the patient she reported not having seen her GP in years and being very nervous about getting them involved. However she agreed to OT completing a joint visit with the Community Matron. This was done and the matron completed a range of clinical observations which indicated cardiac issues. The Matron was then able to arrange to carry out an ECG at home which indicated ongoing unresolved cardiac issues, having been completed at home this was much less distressing for the patient who also suffers from anxiety which exacerbates her condition. A referral was made to cardiology and the patient was diagnosed with atrial fibrillation treatment is ongoing. As the patient rarely leaves her home, she is dependent on an electric wheelchair for mobility, she was extremely anxious about attending the hospital and any tests or investigations or interventions she may require. The Matron was able to involve the team s Health and Well Being Worker - she has been able to accompany the patient to hospital appointments providing continuity and reassurance and also ongoing work regarding her anxiety management
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