Integrated Services Dr Steve Cartwright – Clinical Executive for Integration and Partnerships...
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Transcript of Integrated Services Dr Steve Cartwright – Clinical Executive for Integration and Partnerships...
Integrated Services
Dr Steve Cartwright – Clinical Executive for Integration and Partnerships
Andrew Hindle - Commissioning Manager for Integration
Dudley CCG: context
CCG registered population = 312,000 47 practices 10 single handed practices Mixture of wards including some in the lowest
20% for most deprived across the country and some in the top 20% of most affluent.
Dudley Health and Social Care Economy – The Opportunity
Unnecessary emergency admissions Too many admissions to nursing and residential
care Recognition by partners of the need to address
through a step by step change in service delivery Commitment to redesign urgent care Evidence that 5 day working creates
dysfunctional service pressures
Integration and Better Care Fund
7 day services
Community Rapid
Response Team
OD: Leadership programme
Prevention agenda and tele-health
Risk stratification
Single point of access
Dudley Care Home
programme
Integrated teams
Dudley was successful in applying to be one of the National Early Adopters
Cross health economy working group set up Working with NHS Improving Quality Team Three main areas of focus Mapping of services Developing community standards Sharing best practice with other early adopters
7 day services
Post weekend peaks in admissions Postponement of discharges due to absence
of support services – therapy, pharmacy etc.. Unnecessary admissions due to absence of
more appropriate primary and community health services
Inconsistency of patient experience and response, 7 days per week
7 Day Response To Avoid…..
Community Mental Health Teams: adults
and older people
Palliative care teamHeart failure-
joint pathway with acute
OT
Physio
Care home nurse
practitioners
Stroke
NeurologySocial
service teams
SLT
Current 7 day workingCurrent 7 day working
From July 2014From July 2014
Potential to move to 7 days in 2014
Potential to move to 7 days in 2014
MH Crisis Resolution
Community Rapid Response Team
Tele-care services
Dementia Gateways
District Nurses Current
7 day working
Intermediate Care
Community Respiratory Team
Virtual ward (Case Managers)
Evidence base:- 19,500+ over 65 arrived at ED 14,500 admissions over 65 10,000+ over 75 6,500 admitted for 2 days or less 85% arrived by ambulance
Community Rapid Response Team
Team of 9 Advanced Nurse Practitioners (ANP) Integrated with social care assistants and care
home nurse practitioners ANPs take a referral or co-respond with West
Midland Ambulance Services Assess, diagnose, initiate treatment, instigate
social care package if required and refer to integrated teams
Community Rapid Response Team
Community Rapid Response Team for Older People with Frailty
Integrated with Care Home Nurse Practitioners and Social Care Assistants
PATIENTS
WMAS
NHS 111
GP Out of Hours Community Nursing Teams
Assessment by ANP or Care Home Nurse PractitionerWithin one hour
Step down to Locality Integrated Teams
Single Point of Access forAdvanced Nurse
PractitionerBased at WMAS
Admit to
EAU
- Initiate treatment → - Initiate care package → up to 7 days (then review) - Initiate care plan
Practice integrated teams To consist of GP,
pharmacists, community nurses, named social and mental heath workers.
To review risk stratification tools and agree a Care Coordinator for complex cases
GP Leadership posts in each locality
Service Integration
Infrastructure for integration
A comprehensive organisation development programme
A common Information Technology platform A common approach to care planning An agreed performance framework
Over 2,200 residents in nursing and residential homes registered with a Dudley GP
High number of urgent care admissions Dudley Care Home GP programme operates to
provide proactive care and initiate advanced care plans.
Team of 6 care home nurse practitioners to double in size to be integrated with rapid response team and become a 7 day service.
Dudley Care Home Programme
Proposal is to have a Single Point of Access phone number for community health and social care services
To include a fourth option where there is more than one problem/issue and requires triage.
This will enable effective triage and the call handler takes on the role of a facilitator rather than navigator.
Single point of access
Develop self care programmes Develop technology including remote
monitoring tools (tele-health) Increase utilisation of voluntary sector
(community link workers) Social prescribing
Prevention agenda
Palliative and end of life care
Investment in palliative care services including a new palliative care consultant
Practice identifying more people in their last year of life to ensure a multi-disciplinary team approach and support
Increase and standardised approach to advanced care plans
More people at end of life having choice of preferred place of care
Patient perspectives addressed via the health economy Integrated Working Group
Aim is to capture the actions and improvement that need to be implemented.
Feedback given to the patient, carer or advocate that provided the story/experience.
Learning from patient experiences
Questions?
1. In your case study what elements of the service worked well?
2. What elements didn’t work well?3. What could have worked
differently?