Haringey Better Care Fund Community Event Let s talk about Staying Well 13 th April 2016 Evaluation Report Approximately 50 participants attended the Haringey Better Care Fund (BCF) Community Event which focused on the theme of staying well. Participants were given the opportunity to find out more about the Locality Teams and their plans for the future. (For more information see: http://www.haringeyccg.nhs.uk/about-us/better-care-fund.htm) The event was opened by Marco Inzani, Commissioning Lead for Haringey s Better Care Fund, who also acted a Quiz Master for the morning, as attendees had their knowledge of the Locality Team tested. The event also included two additional participative techniques: Group theatre 1
Group discussions All photography is courtesy of Haringey Clinical Commissioning Group Several themes emerged from these techniques on issues related to staying well and the Locality Team, with the key ones being: Better communication making individuals aware of the services of the Locality team earlier (e.g. upon discharge) Extending the referrals process make it possible for other professions e.g. Housing to make them Continuity of service how will the Locality Team s services extend to other parts of Haringey? 2
Participants had an opportunity to make suggestions on what could be done to improve the Locality Teams. The following table summarises the key themes from these discussions and also provides the response from NHS Haringey CCG and the London Borough of Haringey: You Said 1. You want assurances that the Locality Team will continue across Haringey We Did Haringey s Locality Teams are made up of a Community Matron, Physiotherapist, Social Worker, Community Mental Health Nurse and a Clinical Pharmacist and they work with the GP to help patients maintain health, wellbeing and independence. The Locality Teams are working with GP practices in all 4 collaboratives of the borough Central, North East, South East and West. The Locality Teams are in a pilot phase at present, but have experienced a great deal of success with regards to helping patients stay well and in their homes for longer. London Borough of Haringey (LBH) and Haringey Clinical Commissioning Group (HCCG) are in the process of finalising their plans to extend the service for at least another year. All progress re the Locality Team will be published on the CCG s website: www.haringeyccg.nhs.uk 2. You want the Locality Team s services to be better communicated The Locality Team s services are communicated in the following ways: Visiting patients as part of the team s service delivery. Information about Locality Teams has also been shared at a wide range of forums including CCG public meetings, engagement network events and Better Care Fund engagement events. Information is also available on the CCG s public website. For Professionals (Health, Social Care), via MDT (Multi- Disciplinary Team) meetings and liaison with GPs. Information about the Locality Teams is also available on Haringey s GP website which is used by all GPs and practice staff in Haringey. The MDT team is made up of health and social care professionals. They have regular telephone discussions to talk about patients who have come to A&E several times or have recently been discharged from the hospital. The 3
You Said We Did purpose of this telephone discussion is to help make sure that the right people are involved in their care and to see whether they would benefit from additional support from the Haringey Locality Teams. HCCG and LBH are working on improving communication between health, social care and the voluntary sector to promote better usage of the Locality Team s services. The team have produced a poster that details their service provision, please see Appendix D. 3. You want more information about the Locality Team s referral process The Locality Team is not a service that is accessed by referral. The Locality Team will identify patients as follows: 1. Working with GPs to identify patients who are at risk of an unplanned hospital admission. At present over 70% of GP practices in Haringey have signed up to work with the Locality Team. 2. Proposed by health and social care professionals in the weekly multidisciplinary teleconference or who have been identified by attendance in Emergency Departments. Once patients have been identified the Locality Team will arrange to visit them and will explain the process of how they will work together. 4. You want the Locality Team to be representative of Haringey s residents The Locality Team is made up of representatives from BEHMT (Barnet, Enfield and Haringey Mental Health Trust), Whittington Health and LBH. Recruitment to the team was carried out in accordance with the equal opportunities policies of the employing organisations. 14 participants completed evaluation forms. The key themes from these were: The format of the meeting was very good (the combination of a quiz, presentation, discussions, Q&A and the scenario performances) Overall, the event was interactive and very informative More notice and information about events is needed The event should be advertised better All the feedback will go towards the development of the next BCF Community Event. 4
Appendix A: Haringey Better Care Fund Community Event Let s talk about staying well Wednesday 13 April 2016 Evaluation Form 14 Participants at the Haringey Better Care Fund (BCF) Community Event completed evaluation forms. The comments made have been grouped into themes: 1. What did you like about today s event? Content Making us aware of a potentially useful service Informative event Interactive, very informative The format of the meeting was very good (the combination of a quiz, presentation, discussions, Q&A and the scenario performance) Good subject and information OK for information Information The quality of information provided Receiving information about this project I have collected a lot of information Loved the role play sessions Good presentations The 1 st care display of 80 year old Very good presentation Participation and discussion Good Q&A Time to ask questions Opportunity to meet CCG staff The opportunity to ask questions Enlightened discussion on how to improve the demanding issue of older people Venue and Catering Very nice church 5
2. What could be improved about today s event? Content Is the Locality Team representative (culturally) of Haringey? Are they able to address, is it truly diverse? I hope there will be a follow up to today s event, so that we know say in 6 months time how the BCF is working on real case studies What is going to be the continuity of the Locality team? Participation and discussion The chance to ask questions earlier More time for Q&A Q&A s and debate around important factors to be taken into consideration Not enough time for questions Not enough time to answer the many questions The length of time allocated to each item on the agenda as there is so much to discuss!!! We can only improve services through feedback from the professionals who deal with the issues on a regular basis Starting on time, not too much talking by the speakers Meeting Organisation More handouts More notice and information about events Advertising with GP s leaflets and posters Better visual aids More diverse audience from both sides of the borough When s the next one? More meetings if possible Venue and Catering Meeting location Warmer room Hall was rather chilly More refreshment breaks, tea and coffee served earlier Tea and coffee at the start Conclusion Haringey Clinical Commissioning Group (CCG) and Haringey Council will consider these comments for future public engagement activities for the Better Care Fund. 6
Appendix B: Let s talk about..staying Well: KEY THEMES CONTINUITY OF SERVICE Being assured the service will continue Care Co-ordinator should have a deputy, in case the main one is on leave How will the service get to other parts of Haringey? Roll out services further Ongoing and consistent follow up after pathway has been followed. (not back to the GP necessarily) Long-term sustainability? Commitment? Pilot funding - investment Pilot should be a pilot. It should be reviewed and monitored for its successes and deficits Funding where will it come from to sustain the service TEAM DIVERSITY Ensure the team is culturally representative of clients Employing diverse staff representative of Haringey Service literature should be multi-cultural REFERRALS PROCESS Clear timeframe for when the referrals will be dealt with Make it possible for other professionals to track GP referrals Other professions such as housing should be able to make referrals Could a healthy person who took a turn for the worse be referred to the Locality Team? Extend the service to people who have been recently discharged Locality Team should be more proactive not enough to wait for GP referrals COMMUNICATION Communication must be right ALL must know what is going on Publicity and Engagement Haringey People Told service exists upon discharge Engaging with closest friends Inform carers of the service Notices should be left in GP practices, Sheltered housing and Care homes Carers should have a voice Improve contact with Citizen s Advice Bureau make them aware of this service Give patients a leaflet when they are discharged 7
Appendix C: Let s talk about..staying well Round Table discussion Group discussion: Feedback by table, based on the questions asked. Question 1. From what you have heard, what are the strengths of the Locality Team? Table 1 It is a strength for people who are in need of some support with more on the Horizon? (Early warning) It delivers a holistic service to compliment the GP service A named care co-ordinator is a strength The whole person approach is a strength If the focus is on health, than that is a positive. But if the focus is on continuing care Joint working is a strength Most important issues: It delivers a holistic service to compliment the GP service The whole person approach is a strength Joint working is a strength Table 2 Idea of a multi-disciplinary team is good Continuity Only specialists/professionals on the team (no zero hours) Most important issues: Continuity Only specialists/professionals on the team (no zero hours Table 3 Wide range of professions involved addressing co morbidities Unclear on the role of social worker: -having a social worker is a strength -linkage between Health care and Social care is strong - addressing loneliness Personal touch 8
Locality team is more reactive, which helps with speeding up/solving problems such as getting the doors fixed for example They understand my needs? How does the system work? Locality team been running? Most important issues: linkage between Health care and Social care is strong Table 4 Making life easier for the patient. (Working towards knowledge about the patient in one place) Named care co-ordinator this is can be good, providing their case load is small The team make the referral process better as this done by them directly Multi-disciplinary team - expertise in one place and they come to your home This method leads to the identification of problems (they go into peoples homes, so they will be able to see if there are any additional problems) Most important issues: Named care co-ordinator this is can be good, providing their case load is small This method leads to the identification of problems (they go into peoples homes, so they will be able to see if there are any additional problems) The team make the referral process better as this done by them directly Referral process should be simpler allow more agencies to make them not just: -GP s -acute Professional services such as housing should also be able make them Table 5 Trying - reaching out to the community home Working more closely together: GP Social services Physio Pharmacist Mental health worker often left out Community Matron x2 Patients can talk to the team about their concerns 9
Most important issues: Working more closely with GP s Table 6 Co-ordination/communication across team Multidisciplinary approach GP s know client best Speed Locality refers quickly, + help to get things done Chasing up in a more timely way than (for example) social care Most important issues: Co-ordination/communication across team Multidisciplinary approach Speed Locality refers quickly Question 2. How could the Locality Team be improved? Table 1 Being assured that the service will continue (sustainability) Pilot should be a pilot it should be reviewed and monitored for its success and deficits. Report should go to Adult Social Care Scrutiny There needs to be clarification in Locality Team role in terms of reablement and integrated access Widen the scope Definition is too narrow, more staff more clout and more proactive approach Reduce? dependence on overstretched services (District nurses/bladder and Bowel (continence) Improve contact with Citizens Advice Bureau KEY MESSAGE/ improvement suggestion: Locality should be more proactive not enough to wait for GP referrals. Go to clubs, go to events. Let people know they can refer those who are difficult to reach Table 2 Needs to be fully inclusive (service literature) multi-cultural/languages More publicity about the team and service Encourage family to have more input and take a bit more responsibility The team to liaise with the main family carer and develop a rota of care 10
Education: - more interaction between older and younger people. E.g. joint events at schools and assemblies KEY MESSAGE: Education, education, education Table 3 Extend the service to people that have been recently discharged, to ensure people do not fall into greater risk category help them get early help. Are the right discharge packages in place Could a healthy person who took a turn for the worse be referred to the Locality Team After hospital admissions when people come from hospital, how can they access the early help? Publicity and communication Haringey people Engaging with closest friends especially around consent Discussion around friends and family being able to give consent Could a friend phone up for an assessment on behalf of person in need? Do they have a list of vulnerable people? Notice in GP surgeries Notices in: - Care homes - Sheltered Housing - Day centres Have a leaflet - when discharged (PT and Carer) Told it exists upon discharge Carers being informed Who can we contact by email + send the info about to contact service Table 4 At present, the workload is too focused on care co-ordinator and needs to better distributed Roll out the service further (depending on resources) Care co-ordinator should have a deputy in case the main one is on leave Referral process should be simpler allow more agencies to make them not just: -GP s -acute Professional services such as housing should also be able make them Clear time frames for when referrals will be dealt with Entitlement assessments should make it clear who will be entitled to particular services e.g. OT Make it possible for other professions to keep track of GP referrals 11
Referrals to physio how can other professionals make them? Worries around expansion can/how will this service get to other parts of Haringey Where will the money for large improvements to the home come from? Who will make the care plan for the patient? The care co-ordinator KEY MESSAGE: Continuity: keep this service going by empowering other professionals to make referrals Table 5 Access can you ring the service More appropriate home visits (follow-ups locality team) - increase volume contacts - Safeguarding - vulnerability variable How people can find out about the locality team communication (only know about it today) GP forum Lawrence House Long-term sustainability? Commitment? Pilot funding investment Variable GP commitment e.g. same day appointment IT System - access info by GP - hospital appointment - System GP - change prescription medication/pharmacy Whittington Health Carers Integrated COC team Rapid Response Working together GP Commitment by GP s relationship (comprehensive support) Community mental health KEY MESSAGE: Communication must be right all must know what is going on: - Access to the locality service - GP aware - Professionals involved - Carers have a voice 12
Table 6 We need an ongoing + consistent follow up after pathway has been followed (not back to GP necessarily) where is the funding to back this? Making sure staff capacity is sufficient Making sure staff is skilled enough Closer links with family members/involvement Ensuring the team is culturally representative of clients e.g. culture, language, dietary needs and religion Involvement of local/cultural organisations in the area Community involvement (they may be easier to talk to than a health professional) Employing diverse staff, representative of Haringey with the right skills skills language culture and background Client involvement true representation having their say Background knowledge What happens at the end of BCF? It can t just drain off 13
Appendix D: The Locality Team poster Locality Teams are multi-professional teams that work with GP practices to proactively co-ordinate the care for Haringey residents at high risk of admission to hospital. The role of the team is to support them to maintain health, well-being, independence and promoting self-management of long-term conditions. Service Criteria Persons who are over 18 years or older and are residents of Haringey. Persons who have been identified as being at risk of having an unplanned admission to hospital through either the risk stratification tool or clinical judgement of their GP. Persons who have given their consent to participate in the pilot. Persons who are registered with Haringey GP practices. Contacts Locality Team & MDT Co-ordination Team whh-tr.haringeylocalityteam@nhs.net Telephone: 020 3074 2952 Locality Team Managers Hilary Adams, hilary.adams1@nhs.net Toby Kent, toby.kent@nhs.net Telephone: 020 3074 2930 Locality Team: Community matron Physiotherapist Social worker Clinical pharmacist Mental health nurse GP The Locality Team is not a Rapid Response team for prevention of an unplanned hospital admission. 14