MEETING REPORT Healthier Northamptonshire COLLABORATIVE CARE TEAM Meeting/Project Name: NENE CCG Collaborative Care Team Date of Meeting: 28/8/14 Time: 9.30-12 noon LPC Representative Chief Officer Location: Francis Crick House, Northampton 1. AGENDA 1. Welcome and Introductions Update: Where are we now? 2. Confirm and challenge the proposed CCT pathway: Identify risks and issues What are the enablers 3. Identify services that will interface with the pathway: How do the CCT refer into the service How does the service feedback to the CCT 4. Locality Implementation : Locality engagement Outcomes Coms 5. Any Other Business 2. ATTENDEES Name Rosemary Plum Jamie John Debbie Stanley Department LPC Commissioning Lead Urgent Care, Nene CCG Commissioning Development Manager, Corby CCG 20 x various Primary & Secondary Care, Mental Health, Submitted by: Rosemary Plum 1
3. CONTACTS Name Department Phone Email Rosemary Plum LPC 07785 378030 Jamie John NHS Nene/Corby Clinical Commissioning Group 01604 651291 jamie.john@neneccg.nhs.uk Debbie Stanley Corby CCG 01536 560420 debbie.stanley@nhs.net Tracey Angus Kettering Locality (Nene CCG) 07703 280377 Tracey.Angus@neneccg.nhs.uk 4. REPORT OBJECTIVES Development and Commissioning of Collaborative Care Teams as part of the Healthier Northamptonshire Frail and Elderly workstream. The Scheme is an integral part of the Community Hubs programme. The aim is to provide a multi- disciplinary approach to managing the most vulnerable patients in the community whilst ensuring continuity of existing services in Localities and enhanced management of the most vulnerable population. CCT Pathway Mapping GP practices identify 2% total list size. (Note: The number of patients identified initially will need to considerably exceed 2% to allow for those not giving consent, DNAs, etc.) An invitation is sent to each of those identified to arrange a clinical appointment and draft a personalised care plan for that patient. Patient consent will need to be obtained as the care plan will be shared with other parties such as the Care Co- ordinator. The resulting 2% list size is prioritised into categories. Some cases can be managed effectively within General Practice and will not need to be dealt with by the Care Co- Ordinator and PAC (note the PAC referred to is not the PAC in its current form, but has wider MDT involvement). The remaining patients are effectively handed over to the Care Co- Ordinator, who brings the caseload to the PAC meeting for discussion with GP and wider MDT, and a more comprehensive care plan will be formed. [Note: A Terms of Reference may be required to determine those patients who ought to be handed to the Care- Co- Ordinator and PAC, taking into consideration: - Hospital admissions: based on discharge information to practices. How do we identify patients that require ongoing support? - Palliative Care - Care Homes - Long Term Conditions - Mental Health] Submitted by: Rosemary Plum 2
Of those discussed at the PAC, a large proportion of these patients will not warrant clinical interventions and instead require involvement from the Voluntary Sector, Social Care, Housing, Local Authority, etc. A smaller fraction of cases will need to be dealt with by a clinician (GP, Community Nurse, etc.). In both cases, feedback to the Care Co- Ordinator is required so that the care plan can be updated and discussion with GPs can take place. If the patient s needs are met and no longer require intervention, they can be removed from the CC caseload and replaced with new cases. How does this list refresh itself? SEE APPENDIX 1 at end of this report for Clinical Pathway Map BACKGROUND This is the second meeting to which the LPC was invited. REPORT - MEETING 28/8/2014 The CCTs form part of the Care out of Hospital strategy and they will be implemented in each Nene CCG locality. Each locality is at differing stages of implementation and there are variations across the models being proposed. Some localities are using the GP Federations to manage the CCT, others are using NHfT and others are dependent on the voluntary/3 rd Sector. Kettering: using NHfT as the main provider South Northants: using Principle Medical Ltd (GP Federation) as part of their Transformation of Primary Care Funding scheme to support pro- active care implementation. Wellingborough: proposing care coordination through the 3 rd Sector and linking into pro- active care. East Northants: finalizing a proof of concept paper for care coordinators; alternatively they will request to receive funding within the GP Practices that will do it themselves. They may also consider outsourcing to the charitable sector. Northampton: GP Alliance will be implementing the CCTs from 1 st November 2014 and will be employing care coordinators or GP Practices will opt to have funding for managing the teams themselves. Corby: have already concluded a proof of concept and had their full business case approved. Currently drafting the full service specification using NHfT as a provider. Corby CCTs will be operational from September 2014. Across all localities, there s an urgent need to address governance issues and the access of patient medical records by members of the 3 rd Sector. There has to be only one IG solution across the nine areas. A Risk Stratification Tool has been developed to help identify the non- frequent flyers who are in need of the provision of direct patient care. It s acceptable to operate using assumed consent and it s sufficient for each participating premises to display a poster confirming the scheme is in operation. Patients not willing to give consent must opt out and this should be recorded. Submitted by: Rosemary Plum 3
GP s will be creating universal care plans for patients to use with any HCP. All stakeholders in and out of hours should recognise the care plan. Clear specifications are required with quick and slick referral pathways. The CCTs work with all patients over 18yrs as an additional spoke in the wheel scheme. The clinical responsibility for all patients will always remain with the GP. The overall intention it to support in helping patients stay at home. The CCTs will be a one year pilot project with all aspects of patient experience, finance and quality needing to be evaluated. Nene and Corby CCGs have to hit a target of 10% reduction in avoidable admissions. Both CCG Boards have approved the CCT model with Proof of Concept still to be signed- off by the Boards. All stakeholders are asked to encourage individual GP Surgeries to engage with this scheme UPDATE Meeting 4/9/14 with Tracey Angus, Kettering Locality Lead Kettering are very keen to integrate community pharmacy in their delivery model from the outset. The locality has 8 GP Surgeries and 103,000 patients. GPs are keen to develop this type of integration. Areas relevant to the CCT model include: MURs Domiciliary MURs NMS Discharge Medicines Service for transition from Secondary to Primary Care on discharge LTC Respiratory pathways LTC Diabetes pathways Slips, trips & falls prevention 5a. ATTACHMENTS Microsoft Word Document 6. ACTION ITEMS Action Owner Due Date Provide details of MUR/NMS and other pharmacy services RP 5/9/14 Meet with Tracey Angus, Kettering Locality Manager to discuss specific Kettering pilot with Community Pharmacy RP 4/9/14 Submitted by: Rosemary Plum 4
7. FURTHER DEVELOPMENTS NORTHANTS ONLY Action Owner Date Kettering Locality keen to develop their model with community pharmacy integration RP + LPC support tba 4/9/14 8. NEXT MEETING Date: Objectives: w/c 8 th Sept 2014 Develop model further Time: Tba Location: Tba 9. BENEFITS OF CONTINUED ENGAGEMENT Benefit Integration of pharmacy services into CCT pathways Potential for development of new services for pharmacy RECOMMENDATIONS: Continue engagement Submitted by: Rosemary Plum 5
Yes GP produce >2% list (to allow for DNAs, consent not given, etc.) Yes Identified patients invited for appointment to discuss scheme Appointment. Patient consent gained. Produce Draft Care Plan for 2% patients List divided into categories based on patient needs Influencing Factors: Discharge Information Palliative Care Mental Health Care Homes LTC Cases managed within General Practice without requiring PAC input Cases handed over to Care Co- Ordinator No longer required on Care Co- ordinator list Caseload brought to PAC meeting for wider MDT input and comprehensive Care Plan produced Small number of cases requiring clinical intervention (GP, Community Nurse, etc.) A large proportion not requiring clinical intervention. Does the patient still require intervention? Care Co- Ordinator Liaises with Voluntary services, social care to meet patient needs No Appendix 1 No Does the patient still require intervention? CLINICAL PATHWAY MAPPING Submitted by: Rosemary Plum 6