Torfaen South Neighbourhood Care Network Action Plan 2015-16 1
Torfaen South Action Plan 2015/16 Strategic Aim 1: To understand the needs of the population served by the Network 1.1 Smoking 1.1.1 Smokers in the area quit smoking (SEE APPENDIX 1 ACTION PLAN) Retained as a priority 2015-16 agreed 16.07.15 Links to Communities First Healthy Lifestyles project Links to MIND you in mind project for young people NEW suggested action on smoking cessation Build on what has been started in 2014/15 Regularly review the data on uptake of smoking cessation services Recovery plan if progress Increase number of Smoking Champions (Source: JW Presentation 16.07.15) Number of is reduced in line with target i.e. 5% of smokers make quit attempt with at least 40% CO validation quit rate at 4 weeks PH/SSW Third Sector Social Services 31.3.16 Torfaen action plan developed ABUHB R&D poster developed Networks team working with PHW to secure current data issues with SSW data systems redesign leading to delays Management Team Priority Highest number of smoking champions in Pan area Highest referral rate to SSW in Pan area 1.2 Obesity 1.2.1 NEW: Tackling obesity (linked to 3.5.1) Adopted as Population Needs priority 2015-16 Links to Communities First Healthy Lifestyles project No. 5 1.3 Bowel Screening Identify baseline data for area Measure height, weight and electronically record BMI Intervene more regularly, with right information in the right way brief advice / intervention Map Level 2 services for weight management and refer/recommend Foodwise, commercial clubs, NERS, led walks Refer routinely to Adult Weight Management Service Consider increasing AWMS capacity for specific populations (e.g. Prediabetes, pregnant women) e.g. BG West/Mon North Number of patients who receive timely and appropriate support based on their needs; AWMS guidelines are implemented AWMS// Public Health/Practi ces/third sector/abuh B Divisions 31.3.16 to establish sub-group to take forward with clear outcomes supported by Public Health team Diabetes presentation given at meeting Diabetes Consultants aligned to s Consultant email advice line open Consultant/DSN telephone advice Management Team Priority Draft action plan developed via Management Team 2
1.3.1 NEW: To increase up-take of bowel screening to achieve 60% target Adopted as Population Needs priority 2015-16 /4/5 To achieve national target of 60% for eligible patients; PHW liaise with national screening to provide list of non-responders to quarterly; PHW to calculate predicted increase in referrals for follow up colonoscopy for each % increase in uptake of screening; Identify potential funding to support in targeting non-responders: Follow up letter +/- telephone contact etc; PHW data by to monitor % of non responders who subsequently submit a sample after follow up by Numbers of non responders by is available to work out administrative costs of follow up by if needed Complete significant event audits Carry out thematic analysis to identify potential causes of diagnostic delay Earlier detection of bowel cancer data supports improved survival rates; Published evidence shows Practice level interventions have achieved clinically significant increase in uptake; Evidence shows that high % of people responding once to bowel screening will respond again 3 (Public Health led) / national Screening / / ABUHB Divisions 31.3.16 Amber http://qir.bmj.com/content/3/ 1/u205661.w2324.full u205661.w2324.full. pdf Bowel screening up-take 2013-14.docx Screening For Life 2015 by Public Health Wales - https://www.thunderclap.it/pr ojects/27059-screening-forlife-2015 information circulated to members PH meeting AWBS team 08.09.15 take outcome forward All have received list of non-responders from PH team and targeting with agreed funding 1.3 Engagement 1.3.1 REVISED: Identify a range of methods to increase awareness of the work of the and Map options Continue to up-date ABUHB intranet page To support development of a public facing web-page Scope potential for (slippage) funding for partner held sign-posting web page Feedback analysis leads to evidence to inform improved service delivery with increased patient satisfaction TVA Communities First Bron Afon Housing 31.3.16 Identified as a shared outcome in the Torfaen SIP Torfaen Talks - http://www.torfaen.gov.uk/en /AboutTheCouncil/Torfaen- Talks/Torfaen-Talks.aspx Issues relating to Torfaen residents/communities Links made with ABUHB Engagement Team to identify Torfaen specific events 1.3.2 NEW: To build communication To liaise with Torfaen CBC Lead / 31.03.16 TCBC/Education reps invited
links between Education and Primary Care Team Around the Family (TAF)/Families First programme to scope issues and develop an action plan access to Primary Care/Commun ity services for CYP in full time Education TCBC / Partnership Manager / to future meeting Meeting with Education/Careers Wales being set up by Clinical Director Education reps attended meeting (Nov) to discuss new referral forms for GPs following launch with Headteachers 22.10.15 To be discussed at LMC Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients 2.1 Access 2.1.1 REVISED: To avoid lost appointment slots To review the processes for missed appointments (DNAs) and share good practice To map alternative options to General Practice e.g. Social Prescribing to reduce demand Maximise use of appointment slots to reduce wasted time within / 31.3.16 Gwent wide access SCP for 2015-16 Year end comparison possible when data revisited Cluster Level Report - Measure 44 - GP DN 2.1.2 NEW: Increase access to primary care based Phlebotomy service Implement local service closer to home and in care homes Increase access to phlebotomy service for house bound population Increased capacity within/access to District Nursing service / ABUHB Divisions / District Nursing service 31.3.16 4.4m funding approved for new Phlebotomy service (WAO report on district nursing indicates that 30% of community nursing time could be released, for example to manage LTCs, if no longer required to take blood) 4
2.1.3 NEW: Contracted Services: To funding to facilitate AMD / / engage with and utilise skills of recruitment CDs / other Primary Care services i.e. Contractors act as advisors to leads Optometrists, Pharmacists & s with communication Dentists plan established Increased communicatio n leads to improved understanding of Primary Care issues 31.3.16 funding agreed to support this Scope of contribution to be discussed/agreed All Gwent Independent Contrac All 3 posts appointed to 2.1.4 NEW: Early warning for anticipating difficulty with recruitment/filling vacancies 2.1.5 NEW: in difficulty have access to salaried support team to ensure continuity of service in the short term / Primary Care Plan 2.1.6 NEW: Monitor the continuation and uptake of My Health Online to inform verbally/in writing if having or anticipating difficulty Agree to meet with the lead to discuss next steps As above All practices to offer appointment availability and repeat prescription ordering via MHOL Continuity of services Support against potential Practice fragility Continuity of services; Support against potential Practice fragility Ease of access to GP services / AMD / lead 31.3.16 As above 31.3.16 / / Pharmacy Advisors Strengthening General Practice_ Act QOF 2015 plan for primary care.pdf QOF 31.03.16 Clinical Director appointed as lead with support 2.2 Dementia 2.2.1 NEW: Dementia Roadmap: To raise awareness of information available in relation to accessing dementia care support /4/5 Implement and promote Dementia Roadmap Dementia Friend training is made available Number of dementia friends / number of completed WAMHS training / Phil Diamond DFC lead 31.3.16 0.24 million for national dementia nurse led programme to train care home staff and respond better to their needs and ensure their diagnosis is recorded on GP registers funding allocated to 5
2.3 Workforce 2.3.1 NEW: Practice staff can access timely, relevant training Establish a Divisional/ Task & Finish group training plan developed Develop a process for Practice staff to access training Training providers and costs are identified are informed of training options and criteria Quality of care / skilled workforce enables sharing of ideas/skills and good practice / ABUHB / support implementation of an on-line dementia Roadmap steering group in place 31.3.16 funded Process in place via proposal applications T&F group established 2.3.2 NEW: Ensure local support structure is fit for purpose to meet demands of strategic development Implement a /Integrated Management Team Agree local framework / membership to underpin strategic development Terms of reference developed and ensure all members/ have equal standing in decision making process guidance, coordination and development to meet the needs of the local population lead / HoPN / PC&ND / ISPB / 31.3.16 Workshop held with key stakeholders to agree membership of Management Group, remit, immediate action required and next steps Action Plan developed Strategic Aim 3: Planned care to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harm 3.1 Secondary care 3.1.1 To strengthen integration at Practice level between Primary Care and PCMHSS Identified as a shared outcome in the Torfaen SIP Links to MIND you in mind project for young people NEW: To receive regular performance reports to include referral data specific to South Torfaen, and to identify action required across & Evidence shows services collaborate to ensure timely access to support 6 PCMHSS / MH Division 31.3.16 GAVO Mental Health Service Directory for G Representation at Management Team meetings On-going dialogue and reporting via meetings
3.2 Health Visiting 3.2.1 REVISED: Continue to build Work with ABUHB Divisions / / positive relationship between to improve ABUHB Health Visitors and GP communication via named HV Divisions assigned to each Practice Identified as a shared outcome in the Torfaen SIP 3.3 District Nursing 3.3.1 To improve communication with General Practice Supports Torfaen draft Older People Delivery Plan 2014 3.4 Diabetes Via Integrated Partnership / Integrated Modelling Group & meetings communicatio n leads to quicker resolution & benefits to patients / carers & families communicatio n leads to quicker resolution & benefits to patients / carers & families / ABUHB Divisions 31.3.16 have named HV HVs need to have named link person lead to meet with Clinical Director to agree action required Evidenced via meetings Management Team rep to attend Practice Managers meeting to discuss issues 31.3.16 Service remodelling on-going to align with integration agenda 3.4.1 To improve prevention and treatment of Diabetes (linked to 1.2.1) Links to Communities First Healthy Lifestyles project /4/5 To Implement the Diabetes Dashboard across all and monitor on regular basis Support implementation of the new service model Increase number of referrals to Foodwise project Access to advice from multidisciplinary team & implementatio n of new diabetes work plan leads to improved outcomes for patients PC&ND / ABUHB Divisions / Diabetes Nurse / Public Health 31.3.16 Primary Care diabetes specialist nurses Practice visits held Presentation given at meeting Further action agreed Strategic Aim 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 4.1 Frailty 7
4.1.1 To improve access / communication with CRT / Frailty / Out Of Hours Service Identified as a shared outcome in the Torfaen SIP Supports Torfaen draft Older People Delivery Plan 2014 To map communication issues/barriers re good governance e.g. informed when patients are under CRT; Work with OOHs to identify barriers and solutions communicatio n and colocation leads to better working relationships & care planning Torfaen Integrated Modelling Group / / 31.3.16 Integrated Modelling Group established to progress Torfaen Hub development Initial Scoping Assessment Tool developed with option appraisal & links to Clinical Futures CORE reports developed Strategic Aim 5: Improving the delivery of end of life care ([EOLC] National Priority to be discussed locally) 5.1.1 Review delivery of EOLC using Individual Case Review Audit Links to ABUHB Service Change Plan No. 4 to support to review audit of patients who have died to be reflected upon/inform future care delivery Audit outcome leads to improved care during End of Life phase Leads / / Support 5.1.2 Summarise case review data, and any arising issues and actions identified, for sharing with the network and the wider health board No. 4 Highlight best practice for improvement to be highlighted and shared in a multiprofessional discussion Learning through shared experience will inform improvements for patients on the EOL pathway Leads / St Davids / / Support 5.1.3 Establish a review cycle, to monitor progress (or maintenance of high quality), report to and wider health board as appropriate No. 4 5.1.4 NEW: Themes identified by audits lead to agreed action Agreement of best practice in EOLC. Identification and monitoring of areas for improvement so that appropriate education and support can be delivered to discuss +/- use of EOLC template for all patients consistency in standard of care delivered consistency in 8 Leads / / Support Audit outcomes reported to GP Macmillan co-ordinator with learning points included in the Palliative care Delivery Plan.
who enter terminal stage of standard of Lead illness, not just those with care No. 4 cancer; delivered. HoPN to discuss READ Code training for Practice staff to improve recording of diagnostic symptoms; Develop patient recording protocols for Care Homes, by using the Integrated Care Pathway framework, to ensure patient record consistency; identify carers and record when patients are first diagnosed / placed on the register Ensure Carer s Packs are available at all GP ; To map/ensure access to interpreter services for patients whose first language is not English; Improve communication with OOH Services re Special Notes and use of Adastra to provide up to-date patient records. Strategic Aim 6: Targeting the prevention and early detection of cancers (National Priority) 6.1.1 Review care of all patients newly diagnosed between 1 January 2015 to 31 December 2015 with lung, gastrointestinal & ovarian cancer No. 4 Audit tool Patient referral information reviewed and Outpatient appointments / results followed up / Leads / NICE issued: Suspected Cancer recognition and Referral NG12 (June 2015) GI Consultant attended to discuss learning points and solutions impact of new NICE = WLIs / Weekend & evening clinics 9
6.1.2 Learning and actions to be complete audit and / shared with and the wider discuss findings Leads / health board as appropriate No. 4 Audit tool ensures continuous review, reflection & improvement in processes/ care pathways for cancer patients 6.1.3 Identify and include relevant actions to be addressed in Practice Development Plans No. 4 Practice by practice USC cancer data will be collated to provide better informed demographic data relating to cancers on a regular basis patient information/ Patient choice & preferred place of death / Leads / 6.1.4 Summarise themes and actions for review with / share information with wider health board as appropriate s to share learning with secondary care As above / Leads / No. 4 6.1.5 NEW: Themes identified by audits lead to agreed action No. 4 Develop protocol to refer patients as USC if cancer suspected with Practice based referral tracking system; encourage patients to attend Bowel Screening Programme; GPs are informed by Secondary Care Consultants when referrals are reprioritised; Patients who DNA are patient information Appropriate treatment pathway initiated PC&ND / AMD / ABUHB Divisions / / lead / 10
contacted Strategic Aim 7: Minimising the risk of poly-pharmacy (National Priority to be discussed locally and also Medicines Management) 7.1 Poly-pharmacy 7.1.1 Identify and record numbers and rates for patients aged 85 years or more receiving 6 or more medications. 7.1.2 Undertake face to face medication reviews, using e.g. No Tears approach Using audit +, a review of practice clinical systems to identify ( at-risk only) patients over the age of 85yrs in receipt of 6 or more medicines. NEW: Consider extending the audit age range to include lower starting age Using data from the review audit book appointments for medication reviews of patients over the age of 85yrs receiving 6 or more medicines. Identify patients at high risk or harm of either over/ under medicating Reduced avoidable admissions; Identification of untreated condition(s); Number of MUR Consultations Leads New Pharmacist in post Leads / / Support New Pharmacist in post 7.1.3 Identify any actions to be addressed in Practice Development Plans 7.2 Medicines Management Poly-pharmacy at meetings Quarterly information to on utilisation of notional budget As above / Prescribing advisors / / Support 7.2.1 NEW: Recruit Primary Care based Pharmacist from funding to integrate with GP Initiate recruitment process Summer 2015 Induct Pharmacists into GP Pharmacists project team leads//p C&ND 31.3.16 Post appointed to July/August 2015 11
, and developing a Integration and outcomes suite of Supports IMTP measured/ monitored via priorities & SCP3 meetings outcomes; 7.2.2 To monitor the prescribing budget and delivery of the Medicines Management plan To receive regular prescribing information (at meetings) Budget performance and delivery of the savings plan National Indicators / Clinical Effectiveness Prescribing Programme Pharmacy and Leads to meet and decide on priorities for s to achieve in terms of service improvement, costs and quality Patients and professionals have access to a named Pharmacist in Primary Care Efficient use of resources leads to reinvestment & more appropriate care Lead / Prescribing lead / priorities - outcomes.docx Induction carried out to introduce post holder to etc Outcomes agreed via project group discussion re local requirements e.g. face to face reviews / de-prescribing / optimising dosages but with close liaison/discussion with GPs meeting agenda item with scrutiny of actual and projected spend against prescribing budget 12
7.2.3 To review the variation in Patients and prescribing compared to professional national guidance in relation to have access to Diabetes and Respiratory and a named deliver the savings target Pharmacist in for these work-streams within Primary Care the three year plan s to work with Primary Care and Networks Division Pharmacy staff to: Arrange scheduled visits by the Lead to discuss Dashboards and Practice performance; Monitor performance change through actual prescribing spend on high dose corticosteroids and diabetes drugs; Identify prescribing leads rep and identify progress against the SCEP; Prescribing guidance to be developed by Pharmacy Team Strategic Aim 8 Delivery consistent, effective systems of Clinical Governance No Objective Agreed actions Outcomes Key 8 Clinical Governance 8.1 To fully implement the Clinical Governance Toolkit To ensure practices are supported in completing the CGSAT Sessions to be established to support GP practices in completing the CGSAT Target support for areas of the CGSAT which are identified as showing low levels of achievement Access arrangements - core access arrangements; aids to access user experience; the impact of My Health On Line. How practices respond to urgent requests and same day requests from care homes, Welsh Ambulance Services Consistency and safety in Practice and wide primary care services 13 / PC&ND / Lead Practice visits by Lead to present COPD dashboard and discuss prescribing issues Regular updates at meetings by Prescribing Advisors Prescribing switch options discussed in the round Pharmacy Technician Practice visits to identify and discuss potential cost efficiencies
No Objective Agreed actions Outcomes Key and Hospital emergency departments. Actions to foster greater integration of health and social care. Consideration of how community resources can be maximised to meet local needs. Consideration of how Third Sector support may be maximised Map local GP services to highlight where services are delivered across practices (for example, contraceptive services, minor surgery) How new approaches to the delivery of primary care might aid service delivery and ensure sustainability of local services. Consideration of the impact of local care pathway work relating to previous QOF work Strategic Aim 9: (Focus Point 10): Other Locality issues 9.1 Obesity NEW: See 1.2 14