CHEADLE & BRAMHALL NEIGHBOURHOOD ENGAGEMENT WORKSHOP SESSION THREE 18 AUGUST 2015 2.
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Transcript of CHEADLE & BRAMHALL NEIGHBOURHOOD ENGAGEMENT WORKSHOP SESSION THREE 18 AUGUST 2015 2.
2
CHEADLE & BRAMHALL NEIGHBOURHOOD
ENGAGEMENT WORKSHOP SESSION THREE
18 AUGUST 2015
3
Purpose• To design an approach for the identification of patients requiring complex case
management and a pathway for the delivery of multi-disciplinary group management; in Bramhall & Cheadle Hulme and Cheadle, Gatley & Heald Green neighbourhoods.
Outcomes• Reviewed the outputs from session two together• An understanding of the lessons learnt from the Marple and Werneth multi-
disciplinary complex case management programme• Designed a pathway for the delivery of multi-disciplinary group management in
Bramhall & Cheadle Hulme and Cheadle, Gatley & Heald Green neighbourhoods• Design an approach for identification of patients needing complex case
management in Bramhall & Cheadle Hulme and Cheadle, Gatley & Heald Green neighbourhoods.
Development phases
Core teamGPs , DNs, SWs
Core teamPlus 3rd sector
Core teamPlus 3rd sectorMental Health
Core team Plus 3rd sector, Mental Health, Therapy, Intermediate tier
Full new Out of hospital service with prevention, planned and urgent links
Plan Do
Study Act
Plan Do
Study Act
Plan Do
Study Act
Plan Do
Study Act
Plan Do
Study Act
HabitsBehaviours, skills and knowledge needed.
Culture development – the way we think and behave around
here
ProcessesMechanics,
meetings, protocols etc. How decisions
get made, risk, assurance and performance frameworks
StructuresWho is responsible
for what (accountability) and
distribution of functions/tasks (responsibility)
Leadership culture which supports and motivates our staff to provide the best care to our patients
COMPLEX CASE FINDING AND MANAGEMENT:
Learning from Marple and Werneth
What do we mean by complex?
In Marple and Werneth:
Any person who is over the age of 18 and is a Stockport resident, a person with a long term condition and one or more of the following will be identified as having complex needs:• The person will have been identified as benefiting from a multi-agency approach to
support their care.• The person has been identified as being at high risk of readmission to hospital • The person’s condition, social band or functionality has deteriorated or become
unstable
However:• Many people with multiple conditions are managing well with the support they have• Often social circumstances are what makes a case complex – housing issues, debt,
isolation, family dynamics
Require complex continuous care
‘Layered’ issues
Frequently require services from
different practitionersMultiple chronic
conditions
Ability to perform basic daily functions affected
Frequent hospitalisations
SHARED AIM
• To wrap care around the needs of people with multiple layers of complex health and social care needs, and their carers.
• To develop personalised, holistic care and support plans with people to ensure they can live the most independent life possible and stay in the home of their choice.– To anticipate and plan for escalation or deterioration.– To manage their medical illness and social care needs.– To promote self care/management– To agree the plan, and thus its implementation, with the person in
the context of their own personal goals
CASE FINDING
• Predictive modelling– Patients at Risk of Readmission - Combined PARR
• Some appropriate cases, but many that are managing well or appropriately• Regular updates work best as list changes quickly• Historical data crisis often over by time flag.
– Multiple comorbidity • Some appropriate cases, but many that are managing well or appropriately• Does not change in the same was as PARR
– Frailty
• Other methods– Personal recommendation
• from hospital• from partners – NWAS, Housing, Third sector, Private Providers• People making contact at any point in the system that would benefit from other
involvement (routine or unplanned face to face, HWB check etc.)
CASE SHARING
• Multi-disciplinary Neighbourhood Service case sharing– Regular meetings – at first– Emails / Telephone calls– By the kettle
• Case coordinator• Consent• Everybody’s responsibility to participate by finding and sharing cases• Rapid discussion and assessment of need and support• Share pertinent information to avoid duplication• Understand colleague’s roles, capacity, and skills• Trust one another’s judgement and abilities• Available to act on what is being asked
“I saw Mrs X today... I think she needs support
with …..”
“Could you give Mr Y a call about ……”
“Did you know Mrs Z went into hospital last night…
CASE MANAGEMENT
• Holistic assessment• Case coordination• Personalised care and support plans that plan for
deterioration / escalation• Continuous information flows within neighbourhood
service, and access to colleague’s support and participation
• Access to wider support and advice– Pathways for escalation and deterioration that support people in
the neighbourhood, and rapid de-escalation to draw people back to neighbourhood support as soon as possible
– Locality Practitioner Group
• Clarity around who owns clinical risk
LOCALITY PRACTITIONER GROUP
• Meeting needs that cannot be met though neighbourhood service support or intervention, by working with partners outside neighbourhood service
• Joint problem-solving and positively managing risk • Participation from professionals that can supply information and act on it
– GP Practice staff– Nurse Social worker– Allied health professionals Third sector– Pharmacist Mental health– Housing Etc….
• Participation can be virtual and case-related – tel/ video conference• Preparation by case coordinator and participators in advance• Discharge back to mainstream delivery when appropriate, and re-
escalate if required.
GP ROLES IN COMPLEX CARE
• Identification of people with complex need (not just GP)
• Validation of the data from risk stratification• Medical element of care planning• Medical management• Maintaining medical responsibility whist person is in
normal place of residence• Clinical leadership to the multi-disciplinary meetings• Using the model of care as defined
KEY QUESTIONS
• How will you identify appropriate cases?• How will you ensure that the most appropriate person
deals with the case?• How will you prioritise the most appropriate cases?• How will you access specialist and borough-wide
services when you need them?