Principia Showcase 2017 – Elective Care Workshop

Dr Matt Jelpke

Steve Murdock

Sister Donna Rowe

Innovate - Integrating acute and community care

Initiatives include:

• F12 Pathfinder – clinical guidelines, pathways, standardised referral forms, clinical templates

• Clinical Variation methods – Peer-to-peer review, advice and guidance

• Clinical Assessment Service (CAS) and development of standardised referral processes – Referral management

• Triage / Pre-assessment – e.g. within Gastroenterology pathway

• Elective care community services – Gynaecology, Dermatology, Trauma and Orthopaedics, Ophthalmology (ENT and Respiratory in development)

• Secondary care outpatients appointments – patients who do get referred to secondary care arrive fully worked up (e.g. including completed minimum data sets); greater integration between GPs, consultants, and community services; fewer follow ups

• Community services clinic coordinator – post dedicated to managing the range of community clinics operating in Rushcliffe

Elective First Outpatient Attendances – • Over 17/18 Plan by 8.5% or 63 first attendances Emergency Admissions – • Over 17/18 Plan by 19.7% or 61 admissions Advice and Guidance – • Achieving 17/18 plan at 33%

Innovate – Reducing variation between practices

Innovate -

GP F12 Pathfinder, peer-to-peer review, completed minimum data set

Centralised Secretarial Function Standardised approach using agreed referral templates

Referral Management Service (CAS) Mandating correct referral templates and co-ordinating pathways

Triage / Pre-assessment

Ordering of tests and diagnostics Gynaecology, T&O,

Respiratory, Gastroenterology, Fracture

Liaison Service

Community service Gynaecology, Dermatology,

ENT, T&O, Respiratory, Ophthalmology, Fracture

Liaison Service

Secondary Care This processes will ensure only those patients that require secondary care will be referred with

some/all of the following:

• Standardised referral template agreed with secondary care clinicians • Completed minimum data set • Additional tests/diagnostics completed via pre-assessment • Appropriate recommendations for direct listing for procedures (where relevant/agreed) • Indication of the correct clinic/consultant/specialty

Back to GP with advice

Gynaecology, Dermatology, ENT, T&O, Respiratory,

Ophthalmology, Fracture Liaison Service

Elective Pathway

Evaluate – Measuring impact

Total completed referrals

552

Booked to clinic

293 (53%) GP management

60 (11%) Diagnostics ordered

199 (36%)

Booked to clinic

87 (16%) GP management

112 (20%)

Consultant Triage

Consultant Triage

Booked to clinic 380 (69%)

GP management 172 (31%)

Total

Nottinghamshire Digestive Diseases

Interface – “The Gastro Pathway”

Evaluate – Measuring impact

Evaluate – Measuring savings

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2016-17 £20,678 £40,817 £64,032 £87,838 £110,476 £131,928 £149,451 £170,334 £185,947 £209,209 £221,308 £238,097

2017-18 £11,513 £25,766 £42,169 £61,302 £78,287

£11,513 £25,766

£42,169 £61,302

£78,287

£0

£50,000

£100,000

£150,000

£200,000

£250,000

£300,000

Cu

mu

lati

ve C

ost

OP 1st GP Gastroenterology - Cost Rushcliffe CCG

2016-17 2017-18

Rushcliffe CCG: • Month 5 =

£32,189 saving • Full year

estimate = £71,430 saving

Greater Nottingham potential: • £506,480 per

year saving

Evaluate – Patient experience

Example – Community Gynae feedback: Example – FLS feedback:

0 20 40 60 80 100 120

The personal manner of the individualwho contacted you to arrange your

appointment

The information you were given beforeyour appointment

The availability of appointments

The waiting time from seeing your GP toyour appointment

The convenience of the clinic location

The standard of the facilities at the clinic

The waiting time at the clinic

Your overall experience

DNA

Excellent

Good

Average

Poor

0102030405060708090

100

Poor Average Good Excellent DNA

1. The personal mannerof the individuals youspoke to regarding yourappointment

2. The waiting time fromthe point of referral toyour appointment

3. Ease in arrangingappointments

0

20

40

60

80

100

120

Poor Average Good Excellent DNA

4. Did you feel that yourprivacy and dignity wasmaintained at all times

5. Did you feel able todiscuss your condition andtreatment (if applicable)during your appointment?

6. Did you fully understandany explanations about thelikely result of yourtreatment if required?

7. Overall how satisfied areyou with the service youreceived?

Replicate – Spread

Geographic: • The community clinic model as developed in Rushcliffe is poised to spread:

‒ Rollout of Gastro pathway to Greater Nottingham CCGs via Rushcliffe CAS in plan for Q4 2017/18

‒ Greater Nottingham CCGs currently reviewing the community Gynae service for implementation in all CCGs

‒ Community ENT clinic model under development – NHS England has shown interest in the model and how it can be spread to other CCGs

• Fracture Liaison Service has spread across South Nottinghamshire as of Dec 2016 • The F12 Pathfinder is in use in two thirds of GP practices across Greater

Nottinghamshire • Clinical Assessment Service (CAS) is being developed and considered how can be

spread across Greater Nottinghamshire. Laterally within Rushcliffe’s Elective Care: • Spreading pre-assessment/triage model to other specialties once proof of concept is

tested in Gastroenterology.

• What is in it?

• Pathways and referral guidance (national and local)

• Minimum Data Sets

• Templates and Forms

• Tools and helpers (protocols)

• Patient Information

• Useful information (PLCV, contacts etc.)

• What are its objectives?

• Remind & inform busy clinicians of the correct, up to date pathways and templates available for patients

• Signposting information for nurses and GP receptionists

• Reduce clinical variation, standardise data input and output and make everyday tasks more efficient and easy

• Who is it for?

• Everyone! It will benefit all primary and secondary care staff and patients.

• What is it?

• A series of templates built directly into the primary care clinical systems to aid navigation, path-finding & clinical guidance, data entry and referrals for the south and city CCGs

Innovate – F12 Pathfinder

F12 Pathfinder

F12 Pathfinder

F12 Pathfinder

F12 Pathfinder

Evaluate/Replicate – Data and spread

0

200

400

600

800

1000

1200

1400

May June July August September October

Nu

mb

er

of

use

s

Number of coded uses of F12 pathfinder per CCG per month

Rushcliffe (04N)

City (04K)

West (04M)

NNE (04L)

11

20 3

10

1

34 9

10

0%

20%

40%

60%

80%

100%

Rushcliffe(04N)

City (04K) West (04M) NNE (04L)

Number of practice visits from F12 team per CCG

left toVisit

Visited

11

23 7

19

1

31 5

1

0%

20%

40%

60%

80%

100%

Rushcliffe (04N) City (04K) West (04M) NNE (04L)

Number of practices with F12 access per CCG

F12 access Remaining practices

Innovate – Rushcliffe’s Fracture Liaison Service

The vision: to optimise the identification, treatment, and systematic management of those who present with an increased risk of fragility fracture, including vertebral fractures Global evidence demonstrates FLS improves care quality & reduces costs: “.. efficient, preventative model for fracture management” (Mitchell, 2014) Osteoporosis is “a national healthcare priority” (DoH, 2014): • 3 million people affected in the UK (1 in 2 females and 1 in 5 males over 70 years old) • 560k fragility fractures annually:

• 50% of those with fragility fractures require social care • 25% of those sustaining a hip fracture die within 12 months (NICE, 2009)

By “capturing the fracture,” we help prevent 23% of secondary fractures (NOS, 2015) which occur within 12 months of an initial fracture, which results in: • Reduced mortality • Improved quality of life and patient outcomes • Optimised health and social care spend

Fracture Liaison Service

“5IQ” (NOS, 2015):

IDENTIFY new or previous low-trauma fractures, or those at an

elevated risk

INVESTIGATE: FRAX / DEXA / VFA, blood tests, x-ray, PMH / FHx, BH consultation , falls hx: determine

modifiable risks & optimise intervention(s).

INFORM: GP / patient / AHP : credible advice re falls, determining

fracture risk, optimise treatment, lifestyle advice, management

• INTERVENE: optimise care

planning, drug treatment,/analgesia and promote non-pharmacological interventions to reduce primary/ secondary fracture risk

• INTEGRATE: cohesive shared

care between services for optimal management to reduce/avoid fracture risk

QUALITY ASSURANCE: data collection, audit, QA tools (including patient survey)

database management and team CPD opportunities

Fracture Liaison Service – Our current model: an overview

Patient with new/existing

fracture(s) or at an increased risk

of fracture

Acute referral: ED list / GP clinic referrals / DEXA

referrals

Primary care referral:

searches, referrals, self-

referrers

Community FLS

Investigations

To assess bone health +/-a

falls risk;

assessment/medical review

where appropriate

Patient education – an

enabler

Patients engage with their

condition, facilitating self- management

Interventions

To improve bone health,

knowledge &

understanding; referrals to specialist services.

Integration

Shared care & systematic management

Fracture Liaison Service in Notts – “Reactive and proactive”

Systematic identification:

• Patients with new or historic fragility fractures

• 4 and 12 month follow-ups (improved compliance)

• Establishment and maintenance of an FLS database/DEXA recall system

IV Zoledronate:

• As first line treatment : 100% concordance, minor s/e & approx. 50% reduction in hip fracture/re-fracture in 3-5 years

Other benefits:

• High profile community presence

• Support & Guidance For H/C professionals & patients: a ‘Point of Reference’

• Cohesive pathway between FLS and AHPs/Therapy/Falls Services

Audit:

• Falls and Fragility Fracture Audit Programme (RCP)

• Measures against NOS Clinical Standards (2015) / CCG KPIs

Evaluate – FLS data so far

IV Zolendronate infusions: • Annual target: 32 infusions within the community • 2016/17: 153 infusions • 2017/18: 79 infusions so far (as of month 6)

Identifying patients:

• 674 patients identified as appropriate for the service in 2016/17 (the National Osteoporosis society predicted 593 patients in Rushcliffe)

• This highlights the service’s robust risk stratification and identification processes and the relationships established with referral sources

Evaluate – FLS data so far

Replicate – FLS expansion and spread

Expansion and evolution of the service: • The service was primarily commissioned to intervene at first fracture. • Established links between primary and secondary care and investment from Rushcliffe

CCG in 17/18 has allowed for: • Expansion to deliver IV Zolendronate to a wider cohort of patients, including

patients with risk factors for fragility fractures • Facilitation of discharges from secondary care for cohort of patients with

established osteoporosis who have been attending regularly for IV Zolendronate – these patients are now discharged into primary care for follow up via FLS

• All osteoporosis referrals to the Clinical Assessment Service are directed to the FLS – initial advice provided by the community Clinical Nurse Specialist Lead , who can escalate to hospital specialist nursing and consultant where appropriate

• Specialised template on SystmOne for all queries/referrals for ‘osteoporosis’

Spread within Nottinghamshire: • FLS launched in Nottingham North and East and Nottingham West CCGs on 1

December 2016