Initial Response Team & Principal

Community Pathways

Anthony Deery

Nurse Director

Urgent Care

26th February 2014

Northumberland, Tyne and Wear

NHS Foundation Trust

• Population of 1.4 million people

in the North East of England

• Six geographical areas of

Northumberland, Newcastle,

North Tyneside, South Tyneside,

Gateshead and Sunderland

• One of the largest mental health

and disability organisations in

the country

• Income of circa £300 million and

circa 6,000 staff

• Over 130 sites and provide a

range of comprehensive

services including regional and

national specialist services

Initial Response Team

South of Tyne and Wear

REQUEST

FOR

HELP

ROUTING

ST UCT

OPS

LD

ICTS

SL UCT

OPS

LD

ICTS

GH UCT

OPS

LD

ICTS

Home Based

Treatment

Assessment

Gatekeeping

Home Based

Treatment

Assessment

Gatekeeping

Home Based

Treatment

Assessment

Gatekeeping

Information

Collection, Triage &

Routing

11

Gateshead

Rapid

Response

Nurses

11

South Tyneside

Rapid

Response

Nurses

11

Sunderland

Rapid

Response

Nurses

South of Tyne and Wear Model

Service User Experience Carer Feedback

GP Feedback

Wonderful

support! Brilliant team!

Fantastic – a huge

improvement!!

You should have

done it before

Staff Feedback

More

manageable

Skills are

valued

A lot happier Spend

more time

Yes No

Did the Initial Response Team meet your needs?

The Team were

excellent

keep this very

valuable service

going

Service Feedback and Evaluation of Pilot

Principal Community Pathways

A programme to design and implement new, evidence-based community

pathways for adults and older people.

Our ambition is high and is matched by the expectations of service users

and carers. The new pathways will:

• Significantly improve quality for the patient

• Double current productive time of community services by redesigning

current systems

• Enhance the skills of our workforce

• Improve ways of working and interfaces with partners

• Reduce reliance on inpatient beds and enable cost savings

This is not achievable in isolation and to be successful we need it to be part

of integrated work with partners

The symbiotic relationship PCP and Bed Model

Better

Community

Reduced

Beds

Money

available

Virtuous

Circle

Make

savings

£

£

Fewer

inpatients

Reduced cost

Poorer

community

More beds

than

realised

Less

Money

available

Vicious

Circle

Make

savings

-£ Not as few

inpatients

More cost than

realised £

Design Workshop

Workshop Product Specification

Scope Boundaries Principles Benefits People Constraints

Reasonable adjustment for pathway

Check

Does this meet the Product Specification?

Sign off

Ready to test

Design and Standard Work #1

Design and Standard Work #2

Gather data

Invite people

Refine

Week 0 Week 6 Week 7 Week 8

Check

Does this reflect previous discussion and principles?

The design workshop process

Principal Community Pathways –

How people have been involved So far 362 people have attended the 27

clinical and supporting systems workshops,

these have included: GPs, Local Authority

staff, Acute Trust staff, Community and

voluntary sector staff, CCG staff, NTW staff

and most importantly our service users and carers.

• Our Trust-wide Service User and Carer

Reference Group has been involved throughout

• We have presented our plans to various groups

including HealthNet and South Tyneside GP

Education Forum

• We’ve been ‘walking the wall’ with all of our

stakeholders and have so far run sessions for

over 800 people – with more to follow

The “Wall”

Benefits of PCP

Service Users and

Carers

CCGs Workforce

Partners

• Quicker, easier access

• Recovery focused,

collaborative care

• Enhanced packages of

care

• Alignment of care across

partners

• More efficient, safer

systems

• Integrated care

• No ‘bouncing’

• More time spent with service

users

• Clear roles and

responsibilities

• Increased job satisfaction

• Enhanced skills

• Improved communication

and information sharing

• Reduced duplication

Patient

Process step

Carers

Access Assessment Treatment Discharge

24 hour access Contact within 24hrs and offered choice of venue and appointment time

Self referrals No waiting lists Quicker re-engagement when needed

Able to make referrals Can ring for advice and support with or without a referral More informed, clearer plan

Within 7 days of referral receipt Given information to help prepare Text message or phone call reminder Greeted by front of house staff where clinic appointment needed Full baseline physical health check where required

Can be involved if appropriate Common sense confidentiality Assessments for carers

Text message or phone call reminders for appointments Patients receive treatment in line with NICE guidance Peer Support Workers and community workers to help with social issues Treatment and care in the most suitable environment Care plans developed collaboratively

Can be involved if appropriate in treatment planning and delivery Can request a review at anytime and help with decision making

Carer involved in discharge planning and have their own plan Re-engagement process available if needed

Discharge process is

considered from beginning of assessment helping to prepare for discharge Discharge plan includes how to ‘stay well’ and what steps they should take in the event of a relapse

Process step

GP & Partners

Referral Assessment Treatment Discharge

A single point of access for urgent or non urgent referrals using telephone, email, fax or letter 24/7

A copy of the assessment documentation within 48 hours

Where medication changes are required clear guidance and communication will be provided Clear and concise updates and action plans

A clear and concise discharge summary If relapse occurs a simple referral route back into services

Social Services

A single point of access for urgent or non urgent referrals

Co-ordinated discharge process involving all professionals

Part of review process as appropriate Joint treatment planning Holistic view of service users needs

Opportunity for joint assessments where indicated Shared information across organisations

Advice Line

Advice Line

Process step Referral Assessment Treatment Discharge

Community Staff

Inpatient Services

Specialist Services

Co-working

Link worker Specialist service provides a FAQ factsheet and online presentation to reduce repetitive requests for the same advice Earlier consultation for advice

Provision of scaffolding Estimate less usage as staff get skilled up in core services

Quick access to community services to enable transitions from other services

Continued involvement from the community team – in reach model, resulting in less need for inpatient therapies

Timely discharge from inpatients

Clearer plan and responsibilities

Quick referral and allocation of a worker Reduced need for inpatient beds

Discharge will involve all relevant health professionals and partners Positive attitude to risk management and safety planning Social needs addressed sooner

Based on workload not caseload Clear guidance on treatment that should be provided Will match skill set and train staff when needed Quick access to advice from specialist services

Preparation time booked in assessors diary Where possible the assessor will provide treatment Documentation reviewed so that assessment flows better

Streamlined approach to external and internal referrals Open referral system where we can ask more questions from the referrer / service user/ carer More responsive IT systems and less paperwork Access service will gather as much information as possible before the assessment