Newport East Neighbourhood Care Network ction Plan 2017-2020 2018-19 Progress against the plan 1
Strategic im 1: To understand and highlight actions to meet the needs of the population served by the Cluster Network Objective 1.1 Improve Community Wellbeing for Newport Outcome ction, Progress to date & Measures RG Ensure people have a greater sense of control over what they need, making decisions about their support as an equal partner ction/measures Early intervention and preventing escalation by ensuring the right help is available at the right time, close to home Collaborative working across partner agencies Increase in the use of technology to support self-care and management People and professionals are able to navigate the network and people receive the right support, first time The wellbeing workforce is able to support the needs and wellbeing outcomes of the population, ensuring a core offer Implementation of the findings from the PHW IWBN baseline review pril 2018 Progress Community Wellbeing work stream established with joint partners Regular meetings of the CWB held to progress the work plan Care Closer to Home Project Manager appointed September 2018 to drive the work stream forward Development of placed based IWBN by NCN Development of QR boards to support care navigation Roll out of care navigation training for all frontline staff (commencing October 2018) to ensure consistency of I across Newport Establishment of a local DEWIS work group for Newport Involvement in the development of the 4 community hubs within Newport to consistently deliver the IWB offer across each NCN. 2
1.2 Improve Mental Health and Wellbeing for Children and Young People Outcome ction, Progress to date & Measures RG To provide a seamless integrated service for patients, families and agencies involved around the family. 1. Neighbourhood Nursing Years 2& Provision of a nurseled model of holistic Newport agreed as a pilot area for the collaborative PCMHSS model to strengthen integration, reduce duplication across agencies for referrals, assessments and interventions. Select as a National Clinical Priority area within the GMS Contract for 2017/18. Compare number of referrals made into new SP model with previous PCMHSS model Review number of instances PCMHSS Practitioners provide consultation to frontline staff from other agencies and types of consultation (e.g. signposting consultation to ensure CYP accesses the most appropriate support) Raise awareness of other mental health resources available within the community Practices to complete the learning requirements outlined within the Mental Health DES and NCP NCN workshop held on 1 th July 2017 for East and North NCN and partner agencies. ction plan developed to take the proposed model forward and support the pilot. NCN lunch and learn session held on 19 th July 2018 to review progress against the action plan. Work is progressing at pace to develop a transformational model for service provision based on the iceberg model, building on the single point of access model in Newport with Education included, providing mental health in reach to schools, perinatal mental health provision for infants and parents, communityembedded, family-based early interventions for vulnerable families, community Psychology, supporting frontline staff and dedicated senior leadership capacity to make change happen in Health, Education and Local uthorities Pilot area for neighbourhood nursing. G
1.4 Newport East Health and Wellbeing Campus Outcome ction, Progress to date & Measures RG care within the community Year To provide an integrated health provision for all patients within the Newport East NCN Work with Ringland and Beechwood District Nursing Teams to create local integrated teams to deliver care to the people within the local community. Improve continuity of care by reducing the number of hand offs between community teams Promotion of increased independence where possible. Deliver care in a more holistic way. Test and learn site established in Newport East NCN Project team established. Links established with the Newport Care Closer to Home MDT Intermediate Care work stream and graduated care. 6m Capital monies made available by Welsh Government for Ringland wellbeing hub. Newport City homes investing 6m in the regeneration of Ringland, which will include retail and commercial outlets, the refurbishment of Milton Court and Cot Farm Circle. Newport City Council are also undertaking a decentralisation of local services into 5 Neighbourhood hubs across Newport, which will provide public facing services. Programme developed around the delivery of the wellbeing hub in Ringland and Programme manager appointed. Governance structure in place to support the partner agencies to deliver on an integrated basis Feasibility study carried out in September 2018 and schedule of accommodation drafted. Project structure in place and regular meetings and engagement events taking place. 4
Outcome ction, Progress to date & Measures RG OBC being developed. 5
1.5 Communication and Engagement 1.6 Ensure the population is immunised against infectious diseases. Outcome ction, Progress to date & Measures RG Provide Information, dvice and Guidance to support the public to make more informed choices. Improved integrated working to support locality planning. Improve the uptake of childhood immunisations and flu immunisations Ensure the NCN is utilising available resources across the wider NCN partnerships. ttend two engagement events per year to understand the diversity of issues across the NCN. Work closely with BUHB Engagement Team. ttended Gwent wide multi agency / Third Sector event in May 2017 to discuss development of Social Prescribing services within Newport and wider Gwent. Participating in the Engage for Change events across Newport in conjunction with the BUHB Engagement Team (utumn 2018) Regular contributions to the NCN newsletter and Newport Matters Publication (NCC) ccompanying the Newport NCN Pharmacy team at the Choose Pharmacy Event to promote Direct ccess Physiotherapy and Care Navigation ttendance at the PHW Knowledge Exchange in the Parkway Hotel July 2018 Newport Health and Wellbeing Campus engagement commenced on 7 September 2018 Improve the uptake of childhood immunisations across the NCN Share best practice across the 18 GP practices Improve uptake of flu immunisations Ensure all risk groups are identified and processes put in place to immunise this group of patients Regular flu reporting to the NCN Monitor via the monthly core performance reports by Management Team. Regular flu updates provided to the NCNs by email 6
Outcome ction, Progress to date & Measures RG Childhood Immunisation Lunch and Learn provided by the NCN in December 2017 Flu Immunisation Lunch and Learn Session provided by the NCN on 7 June 2018 Strategic im 2: To ensure the sustainability of core NCN services and access arrangements that meet the reasonable needs of local patients including any agreed collaborative arrangements Objective Outcome ction, Progress to date & Measures RG 2.1 Care Navigation Years 2& Ensure people have equitable access to sustainable services across the NCN 2.2 Training and Development Develop a person centered I approach across all front doors within Newport Increase opportunity to access the right help at the right time, preventing escalation Care Navigation SL signed. Newport training dates and workshops 1&2 arranged Communication plan being developed to support the roll out to all citizens in Newport update 2. Direct ccess Physiotherapy n open access physiotherapy resource for access by the NCN. Investigate the added value of having a band 7 Physio post in Newport to provide clinical imaging requests, IPS and injection therapists. Develop triage process to avoid creating a demand on the service. Consider developing a complete MSK direct access for Newport in the future. Information dissemination opportunities for NERS, community and NCC walking and organised groups, Leisure Centre opportunities 7
Outcome ction, Progress to date & Measures RG 2.4 Winter preparedness and emergency planning. 2.5 Extended Care Clarity for processes followed for NCN footprint services in the event of adverse weather and emergency situations. Develop a multidisciplinary approach to enable more efficient, effective, and well-co-ordinated services Ensure a sustainable workforce through creation of new roles and greater skill mix Shift from secondary to primary care: Ensuring people are able to access support close to home Pilot project established on 11 June 2018 SL and KPI s drafted Project team established to monitor progress Encourage all residents to be up to date with their immunisations. ll practices have an up to date winter plan NCN partners to be involved in wider winter contingency planning. NCN workshop held in July 2018 to develop a joint contingency plan with partners Sessions being arranged on an NCN basis to support the development of contingency plans with GP practices. greement of the elements to develop greement of resource to support development and implementation of pilots Establish mechanism to obtain robust demand data from GP practices define the required model for each element, including workforce requirements, operational requirements, triage arrangements, service hours, roles and Responsibilities, Clinical governance, Management Structures, Training & Professional Development requirements, Funding requirements, Development of detailed workforce plan. Continual evaluation of pilots gree governance and reporting structure Direct ccess Physiotherapy pilot commenced 11 June 2018. Project team established and outcomes being monitored. Home visiting services in Beechwood and St Davids practices being audited 8
Outcome ction, Progress to date & Measures RG Support demand management by ensuring the most appropriate and timely response Mental Health Support Worker and DP being employed within Ringland Care Closer to Home project manager appointed September 2018 to drive work stream forward. Programme structure being developed. 2.6 Workflow Optimisation Option appraisal and recommendations on a preferred workflow optimisation model for NCN use, and procurement of chosen option. ction/measures Explore different models of workflow optimisation Produce option appraisal with recommendations Roll out to all GP Practices Progress GP Practices received HERE training in March 2018. Uptake in Newport has been poor as most practices had already developed an in-house method for workflow HERE attending practice managers forum on 4 October 2018 to promote advantages of the system to increase uptake. 2.7 Home Visiting Service Years 2 & Support the development of a sustainable model of primary care service delivery by enhancing the provision of home visits to patients registered with the 18 practices across Newport. Reduce the volume of home visits. Triaging the need for GP appointments would also help to screen out unnecessary or inappropriate requests for urgent surgery appointments. Release capacity in general practice to support longer consultations in surgery for managing complex patients. Increased capacity, typically 1-2 additional appointment slots per day, due to the absence of the need for home visits. Reduce avoidable &E admissions and attendances Reduce the number of 999 calls because there had been no recent clinical review or the deterioration of a patient s condition. 9
Outcome ction, Progress to date & Measures RG 2.8 Estates Strategy. NCN estates are fit for purpose Limiting time for home visits may be adding to an already high rate of emergency admissions from primary care. More time would enable a more detailed assessment. Home visits are typically longer (typically 20 minutes) Reduce waiting times for home visits: visits can take place earlier in the day following triage, compared with afternoon reviews which may lead to deterioration of a patient s condition Improve patient flow into the hospital by admitting Patients steadily throughout the day, rather than the usual pattern of sudden spikes in afternoon or evening conveyances. Draft business case developed NCN funding to support an audit of the NP and Paramedic led services being trialled in Beechwood and St Davids practices. Strategic im : Planned Care- to ensure that patient s needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms. To highlight improvements for primary care/secondary care interface. Objective.1 Graduated Care Outcome RG 10
Outcome RG Strategic im 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. To address winter preparedness and emergency planning. Objective 4.1 Frailty Outcome ction, Progress to date & Measures RG Clearer and more accessible links with the Frailty Team will be developed To monitor CRT referral rates, pressures, trends & address as required Discuss at NCN with partners to address issues e.g. communication between Practices and frailty teams Included in ISPB performance reporting Establish a monthly practice based forum between GPs, Frailty and District Nursing to review a small number of precluded cases to gain a better understand why these referrals were rejected and to develop best practice. (based on the palliative care model) District Nursing to be included in the forum meetings to share information about cross over of roles and responsibilities. Development of an anticipatory care rota for Social Services Home Care Extended hours for the Frailty Service ccess to advice and information (direct contact with consultant) prior to making a referral. Improved communication between GPs and Frailty to avoid duplication of referrals Improve public education around the service 11
4.2 Liver disease prevalence and mortality activity and services provision. Outcome ction, Progress to date & Measures RG facilitate appropriate management of abnormal LT tests and, thereby, more timely diagnosis of patients with liver disease GPs invited to visit Frailty to gain an understanding of cross working between the teams. Pathway under development; anticipating that this will be in place in time for winter pressures. Service hours have previously been extended but a further extension is being discussed (resource dependent) SP have been advised to transfer calls for advice only to teams and where a professional or clinical conversation needs to be held. ll agreed/requested referrals will require capture and recording via SP. Service currently undertaking review of front access models, would be useful to further understand nature and borough demand for calls and any opportunities to improve service education. Potential for e communication around WCCG (e-referral) development and interface with WCCIS. Captured requirements to be fed through BUHB WCCIS Steering Group. To reduce the number of repeat liver function tests following an abnormal LT To increase appropriate testing following an abnormal LT To increase appropriate referrals to hepatology for patients with abnormal LT indicative of hepatic fibrosis NCN Workshop held in September 2017. ction plan arising from the workshop. GDS training provided to primary care. Increased knowledge/awareness of service plan to increase referrals to GDS included as per pathway Pilot scheme for in reach worker into general practice to support and signpost patients, providing a more holistic approach, looking to address more widespread issues (benefit checks etc.). 12
Strategic im 5: GP Contractual Priorities Objective 5.1 Flu Reporting Outcome ction, Progress to date & Measures RG Increased prevention of morbidity and mortality in the NCN footprint due to liver disease. Review of current services and activities to be held. Issues / challenges to accessing and provision of services identified. ction Plan developed. Two Peer reviews held to evidence learning in to practice. Report back impact of changes to NCN peers. Strategic im 6: Medicines Management and Pharmacy. Objective completio n 6.1 Medicines Management Years 1,2 & 6.2 Pharmacy input into General Practice Years 1,2 & Outcome ction, Progress to date & Measures RG Performance management and analysis of the NCN prescribing budget. Provide the most effective and cost Regular updates provided by Lead Pharmacist at NCN meetings Support any outlier results Regular updates with Newport Pharmacy technicians based within the locality office. Community pharmacists attend NCN meetings on a rota basis to support the discussions. ction/measures: Regular updates provided by practice based pharmacists at NCN meetings Practice based pharmacist shares best practice across the NCN 1
efficient treatments for patients Progress NCN Pharmacists appointed by the NCN for Newport East with support offered across the NCN Practices have appointed practice based pharmacists based upon the success of the NCN funded posts. Strategic im 7: Governance Objective 7.1 Clinical Governance Toolkit 7.2 Information Governance completi on nnually by GP Practices nnually by GP Practices Outcome ction, Progress to date & Measures RG Clinical Governance toolkit to be completed and learning outcomes identified and discussed with peers Information Governance toolkit completed and learning outcomes identified Encourage practices to undertake and complete the toolkit. Practices reminded by email and at NCN meetings to undertake the toolkit before Q4 Monitoring of NCN GDPR activities Newport wide GDPR seminar arranged to support all GP practices GDPR information circulated to NCN membership when necessary. G G 14