Clinical Strategy 2012-2017 www.hacw.nhs.uk
CLINICAL STRATEGY 2012-2017 Our Clinical Strategy describes how we are going to deliver high quality care in response to patient and carer feedback and commissioner requirements. It has been developed by our staff and our partners and reflects their priorities for clinical services. This strategy sets out our priorities for transformation for the organisation between 2012 and 2017 and sets out what we need to do to differently to develop our services; this includes the development of new roles and skills, new ways of working and adopting new technologies. Clinical quality is what we are all about and the main purpose of our Clinical Strategy is to provide high quality care we are proud to give and would recommend to others. The principles of this clinical strategy are to communicate to our staff and stakeholders our primary focus, which is: To ensure high quality safe care To deliver the right care for every individual To provide care closer to home To promote recovery and independence To deliver through integrating services Who are we? We provide high quality health and care services across all stages of life. These are delivered in peoples own homes, community clinics, outpatient departments, community inpatient beds, prisons, schools and GP practices. We also provide in-reach services into acute hospitals, nursing and residential homes and social care settings. We are the main provider of community, specialist primary care and mental health services to the population of Worcestershire. We also provide community and specialist services over our borders. Many of our services are integrated with Worcestershire County Council and we work in partnership across the county with voluntary organisations, our commissioners and communities to deliver high quality services. We provide our services to Worcestershire s 560,000 residents across an area of approximately 500 square miles; supporting people to live independently at home, reducing the need for patients to go into hospital. We employ 3,290 staff and have contracts to provide a wide range of community and mental health services which are delivered through our 5 Service Delivery Units: 1. Community Care 2. Adult Mental Health 3. Specialist Primary Care (offender healthcare, dentistry and sexual health services) 4. Children s, Young People and Families 5. Learning Disabilities 2
Our Values Courageous - displaying integrity, loyalty and the courage to always do what is right Ambitious - striving to innovate and to improve through effective teamwork Responsive - focusing on the needs and expectations of people using our services Empowering - empowering people to take control of their own health and wellbeing Supportive - enabling our staff to achieve their full potential and take pride in the services they deliver Our Strategic Objectives We will always provide an excellent patient experience Our services will always be safe and effective We will work in partnership to improve the integration of health and care Our organisation will be efficient, inclusive and sustainable What do we do? We deliver high quality expertise and choices for people with a range of health needs and/or disabilities that enable them to live independently at home or as close to home as possible. What do we mean by this? We deliver person centred care in a range of settings including people s homes, nursing and residential care and GP surgeries which people tell us are the environments they prefer and this helps their recovery. We enable people to adjust their home and lifestyle to meet individual and changing health needs. This can include round the clock highly specialised nursing care, end of life care, intensive psychological interventions, technology to monitor and prevent crisis and/or hospital admission, and carer advice and support. We support recovery by working with people as partners and involving them in decisions that affect them. Promoting independence is an essential part of the care we deliver. This may be by enabling a person with mental health needs to return to work or providing physiotherapy after a stroke to allow a person to achieve their optimum quality of life. We promote health and well-being by working with people who use our services so that every contact becomes an opportunity to promote lifestyle changes, for example stopping smoking and reducing alcohol intake are targeted in sexual health clinics. We provide Integrated Care. This is about delivering care without boundaries and reducing hand overs between different groups of staff or organisations. This provides seamless care for patients and carers and prevents duplication of effort and promotes efficiency. We work alongside a range of partners, including other health organisations, local authorities and housing associations to ensure patients to get the treatment and care they need as conveniently and efficiently as possible. For example in our mental health services we deliver integrated care where social workers, occupational therapists, vocational staff and nurses and doctors work as a team to optimise their skills to prevent or support crisis and promote recovery. 3
How do we know it is right? The outcomes of the care we provide will be demonstrated by how we: Support people to live healthy lives Promote independence and support people with health care needs and / or disabilities to live well Support people to recover following an episode of ill health or injury Ensure our patients and carers always have positive experience of our services Always provide safe and harm free care We have a range of metrics and evidence to help us understand that we are achieving appropriate outcomes for the people who use our services. Examples of the outcomes we monitor are included in Appendix 1. 4
Major Clinical Development Plans Our Clinical Strategy drives the other key Trust Strategies and they in turn support the service developments and implementation plans that are described in our Integrated Business Plan which sets out our direction for the next five years. The key developments that we plan to implement are set out below: We are re-organising our community teams to provide a broad skill mix with the right competencies to meet the needs of the patients without the requirement for numerous referrals and reassessments. The provision of Planned care brings together various community teams into single line managed integrated community service. These Extended Primary Care Teams or Planned Care Teams will work closely with GPs to support people to manage their long term conditions, avoid crisis and stay in their own homes as long as possible. Community Enhanced Care Teams will take over from planned care or the acute hospital to support people to live at home or close to home while they recover, from a serious illness, adapt to a new complex condition or manage a long term condition crisis - e.g. stroke, exacerbation of COPD or unstable diabetes. Across the county we will develop the role of community hospitals into Community Treatment Hubs to manage a greater number of patients with more serious medical conditions or minor injuries, who would have been traditionally treated in an acute hospital setting, to be seen in our community hospitals. We will continue to develop mental health inpatient care, continuing the focus of care provision from Maintenance to Recovery. This work includes increased treatment options for service users, shorter more focused hospital stays, greater diversity of community services and an overall reduction in the number of beds required. We remain committed to the development of an appropriate local learning disability crisis and resolution service to provide very specialist care locally. We will continue to develop the work with Children and Young people to promote health and well-being, support the delivery of universal services in schools, colleges and the community and provide a range of specialist services close to home including for example supporting ventilated children to live at home, Palliative Care services, CAMHs (Child and Adolescent Mental Health Services), and services for children with complex needs. We will continue to implement and evaluate our 24/7 mental health liaison service that provides specialist support for people admitted to acute hospital settings. We currently deliver mental health and learning disability services through integrated teams. This has resulted in greater choice and shared care, which enables patients and carers to access services more conveniently, often in the same building. We will work with the Council to identify options for further health and social care integration to afford these advantages to other groups of patients particularly, but not exclusively, those with long term conditions and the frail elderly. Priorities for pathway redesign / transformation 5
The clinical development plans above will enable the transformation of pathways to deliver more patient centred care. A patient pathway is a way of describing how a patient s care may move between different providers of care; it is a description of the patient s journey. The aim is to make the transition between services as smooth as possible, avoiding duplication and ensuring good communication and handover. When developing our clinical strategy we were aware that there is great enthusiasm for improving patient pathways through our system. The Trust has identified the following areas as priority for pathway redesign and transformation: Sub acute in the community, linked to the emergency care pathway this focuses on community assessment and treatment Older adult, includes frail elderly and dementia care Mental health acute and community care, this covers adults mental health from primary care to acute care Learning disability complex health needs Child and adolescent mental health Inpatient care, this links several pathways but is particularly focused on how the Trust makes best use of its community hospital beds Patient story: Mr Smith is 76 year old gentleman who is referred to the out of hours GP service by his wife. He has a deteriorating chest infection and some degree of confusion. The out of hours GP visits and although considers an acute hospital admission contacts the enhanced care team out of hours and the patient is seen by a district nurse. The GP suspects Mr Smith s confusion may be related to a urinary infection as his wife reports he has been taking reduced fluids for about 2 weeks and his dietary intake has also reduced. The GP prescribes intravenous antibiotics to quickly treat any infection and prevent hospital admission. The district nursing team delivers this care and arranges to visit again later in the evening. They also coordinate follow up visits from the Enhanced Care team as well as further district nursing contact from the Planned Care team. Mr Smith is discussed at the Enhanced Care team meeting the following morning and following a dialogue with the mental health older adult psychiatrist it is not felt that adding a further assessment to his care plan would be beneficial at this stage, but to see what the effect of the antibiotics and rehydration have on his confusion. If the confusion remains the assessment can be added to his care plan later. Mr Smith recovers and his confusion improves quickly with the treatment of his physical health care needs. He has avoided an admission to hospital and has remained supported and treated at home close to his family which was their preferred choice. Equally changing his environment at a time of confusion would have made this worse and inevitably slowed down his recovery. 6
High Quality Care The Trust is committed to reducing harm caused to patients. We will introduce a change programme which will ensure care is delivered with a focus on maintaining privacy and dignity and delivering harm free care. We will achieve this by ensuring patients receive the best care all of the time through our Pledge to Care. This sets out our ambition to ensure: Our patients will have a good experience We will provide a clean, safe and stimulating environment We will be recognised as a trust that cares Supporting Strategies Our Clinical Strategy sets out what we are planning to achieve for patients and carers it also informs other important strategies that support our plans over the next 5 years. We are highly aware of the opportunities and challenges associated with a large and diverse estates portfolio and emerging technologies. These are addressed in specific strategies that set out how we will develop fit for purpose facilities, make use of modern technologies and ensure we have an outstanding workforce. These together will ensure the Trust delivers high performing services. Integrated Business Plan IT Strategy Estates Strategy Quality Strategy Workforce and OD Strategy Membership and Engagement Strategies Clinical Strategy Quality Strategy 7
How does the future look? Progressing our Clinical Strategy During the lifetime of this strategy most of our services will undergo dramatic planned change to deliver against our clinical commitment to support people to live independently at home or as close to home as possible. Patients will talk about our services as being easy to access, providing choice and responsive to their needs. Patients with long term conditions will be identified earlier, managing their own needs in partnership with our staff. They will be able to access timely community specialist support which will be available 24 hours a day, 7 days a week to avert crisis. Where people are appropriately admitted into hospital there will be a wider choice of community services to support them to maintain their independence, enabling them to return home, or as close to home as possible. Our workforce We aspire to be the employer of choice as we believe that motivated and satisfied staff take pride in their work and provide better care. We will develop and recruit staff to our values ensuring the delivery of this strategy. Our workforce will be fit for purpose and clinical leadership will be embedded through the organisation. Our staff will need to develop some new skills to support patients with multiple health needs at home or as close to home as possible. We will provide clinical expertise in all of our services through the further development of skills and competencies and staff will continue to be supported to use evidence and technologies to provide the most effective and efficient care possible. The further development of leadership capacity and capability to drive forward the changes will be vital to the success of this strategy and programmes will be tailored to support this. Staff will be supported to understand their accountability to their patients, the public and the Trust Board for delivering this strategy. 8
Integrated Care Mrs Jones is an 85 year old lady who, following a recent fall, received rehabilitation at home supported by community physiotherapy services. One of the visiting team observed that she had developed a leg ulcer that required assessment and treatment. Her husband also reported that she had become forgetful and recently left the cooker on whilst preparing food. As the physiotherapist was part of an integrated team, she was able to discuss the leg ulcer directly with her district nursing colleagues and arrange for them to visit, assess and treat it. The physiotherapist continued to coordinate care to meet Mrs Jones needs as well as providing continuity even when other professionals were involved. For example, a joint visit was undertaken by the district nurse and specialist mental health nurse for older people to assess the impact of reported changes in Mrs Jones memory. Through this process, Mr Jones was also offered support and a carers assessment as well as the opportunity to access the Admiral Nursing Service. Mrs Jones recovered fully from her fall and her leg ulcer healed. Prior to integration, each of the services added to Mrs Jones care would have required several separate assessments and the physiotherapist would have needed to make numerous referrals to the other services to ensure that Mrs Jones received all the services she needed. This could have taken a number of weeks and there would have been no clear point of care coordination other than her GP. Undoubtedly, this would have felt disjointed with a high degree of repetition for both Mrs Jones and her husband. This joint working approach improves understanding of aspects of care normally outside of one individual s professional scope. Assistive Technology My first fall was a while ago. I hit my head quite hard and was taken to hospital in the ambulance to get tests. I was there for a couple of weeks. I could understand the nurses needing to keep a close on check on me, but I felt ok and just wanted to go home. This time, after I tripped up and fell again I was taken to hospital but then amazingly I was sent home the very next day. I couldn t believe it; it was so nice to get back into my own bed as I really didn t want another long hospital stay. I was sent home with a really simple piece of kit which supports me at home and to live independently. The technology means I can take my own blood pressure and send the results to my GP without having to go anywhere. I am also visited daily by the nurse who comes in to dress the wound and check I m ok. It s like the nurses having their eyes on me, but from a far. Being at home also means my friends and family can come in and visit as the trip to the hospital was just too far for them. It also means the hospital bed I was in for weeks is freed up and available for someone who really needs it. 9
Appendix 1: An example of how the Trust maps its KPIs to Outcomes 1. Support people to live healthy lives % staff trained in brief intervention % staff training in healthy chats 2. Promote independence and support people with health care needs and / or disabilities to live well 3. Support people to recover following an episode of ill health or injury 4. Ensure our patients and carers always have positive experience of our services Patients on Care Programme Approach for at least 12 months who had a CPA review in the last 12 months Therapy outcome measures (TOMS) Patients on CPA discharged from MH inpatient care who are followed up within 7 days Referral to Treatment / access rates and trends Complaints related to staff attitude % of complaints responded to in required timescales % of patients with expected date of discharge Net promoter score Patient experience survey 5. Always provide safe and harm free care MRSA bacteraemia rates C diff rates Infection control training uptake % patients who are harm free % reporting of incidents within 48 hours % response of safety alerts within set time frame Analysis of serious incidents % of NICE compliance assessments completed % clinical audit plans that are running to plan 10
ANNUAL REPORT 2011/12 11
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