Kaiser UpdateMarch 2005

Northumbria/Northumberland

Integrated network of emergency care services – By day

EmergencyCare

We have been interested in

• Long Term Conditions

• Care Facilitation-Interqual

• Contact Centre

• Buildings

• Impressed by– Culture– Use of Information

The Kaiser Triangle

Case Case managementmanagementComplex: co Complex: co morbiditymorbidityHigh resource useHigh resource useCare Care managementmanagementHigh riskHigh risk

Supported Supported Self Self managementmanagementGood controlGood control

Case manager navigator Case manager navigator and support usually and support usually telephonetelephone

More intensive More intensive managementmanagement

Group educationGroup education

Routine medical Routine medical reviewreview

Risk stratification

Population wide prevention

Educated Patient & Carer

Primary CareSpecia

list Team

Educa

tion

and

Traini

ng Use of Information

Community Teams

Whole System Planning & Delivery-3Rs

Chronic Disease Objectives

Expensive, Reactive,

Unplanned Care

Effective, Responsive, Anticipatory

Structured Care

Effective Chronic Disease

Management-3Rs

Patient Empowered

Care Planning

Bob’s Pearls of Wisdom

• The NHS will not be as successful for patients as it needs to be, as long as we still see ourselves as either primary care or secondary care

• What can we do about our structural boundaries?

Clinical Carestream Leads Clinical Director & Locality Manager Clinical Directors Professional Leads Clinical Team Leads

Carestreams

Primary care based commissioning

Priority and Decisions Group (PDG)

PHCT PHCT PMS SW

Clinical Directorates

CPG-Clinical Policy Group

Wards Departments

PEC

Northumbria Board CT Brd

Care Streams

Clinical Carestream Leads Clinical Director & Locality Manager Clinical Directors Professional Leads Clinical Team Leads

Carestreams

Primary care based commissioning

Priority and Decisions Group (PDG)

PHCT PHCT PMS SW

Clinical Directorates

CPG-Clinical Policy Group

Wards Departments

PEC

Northumbria Board CT Brd

Successful Whole System Service Delivery

‘Reid unveils new changes to LTC Care’ – 5th January 05

• Major overhaul of the in the way care is provided to patients will LTC

• Organisations will– Community Matron– Identify people with LTC, 3 Rs– Educate patients with LTC

• National Service Framework (NSF) for Long Term Conditions will be published later this year

LTC-Launch event

• Clear statement of intent-Aims• Clash of Views

– Generalist Vs Specialist views– ‘My Service’ or ‘The Service’– Out of ‘site’, out of mind– Heard this all before

• Boundaries are still a problem• Management

– Organisation vertical/Network horizontal– Capacity-numbers, skills and attitude– Permission and AUTHORITY

• Leadership Capacity• Engagement - Still a problem

Managed Clinical Networks

• Whole system and responsible for the full pathway• Bring to the table ‘the Assets’-and AGREE the plan• Clear Freedoms -Could be beyond ‘the unthinkable’• Fences -What is inside the fence (within the gift) • Decision by agreement then have to deliver it operationally • Statements of roles and responsibilities, freedoms and fences• Clinically led but populated by the right input from the ‘coalface’• Information jointly owned and shared to inform the planning and

decision making processes• Operationally accountable through the original organisations but

jointly responsible through the partnership planning process• Requires Leadership, Engagement, Management

Long Term Condition Partnership Board-Manage the Cross-cutting

themes• Added value• National and local

priorities and targets• Education and Training

opportunities• See the whole picture• Give guidance and

direction to LTC streams• Cross stream Learning

• Relative and comparative risk management begins

• Apply common models• User and public

involvement• Patients with complex

and multiple conditions• Senior clinical and

managerial level input

LTC-PB

M/Skel CVS DM OlderPeople Stroke GI Pall Care RESP

Cancer !Rheum O/porosis

OA Pain

Chronic

Neuro

DM

Resp

CHD

Stroke

GI

M/Skel

Managed Clinical Networks

E&T

Case

Management

Medicine

Management

Use of Information

Cross-Cutting Themes

N’umbria OSM

Department Managers

Ward or other management

Care Trust Managers

Care Trust Staff

Care Trust Directors

N’umbria G.M. and Director

Original Management Structure

Network Manager

Changed N’umbria OSM Role

Wards or Departments

Changed CT Manager and GMs Role

CT Staff

N’umbria Director CT Director

Director for LTC

Primary Care

?Later

First Stages

Existing Structure-(Medical and Emergency Only)

MOB ECOBCIDARUrgent Care Brd

PCOs Northumbria

Access Prim care

14 Care streams

Medicine & Emergency care Board

Northumberland Urgent care Carestream

Long Term Conditions Partnership

Board-LTCPB

Northumbria Care Trust &?PCT

Wider Context

Primary Care Access/ Comm Service

Change in Style

Primary carePrimary care Secondary careSecondary care

D

D

19991999

Primary carePrimary care Secondary careSecondary careSpecialist careSpecialist care

SupportingSupporting

and managing and managing quality diabetes quality diabetes

carecare

20022002

Achievements in North Tyneside 1991 -2001

•Structured Care District wide 97%•Biomedical measurements 80 – 97%•Satisfaction with care 84 – 95%

•Sustained for 10 yearsalso

•Reduced amputation rate / Reduced bed occupancy

All measures equal to those achieved in the UKPDS but with routine care – a majority within primary care

Respiratory Services-Winner of National Award for LTC

• Individualised assessment, in hospital, outpatient clinic and at home

• Promoting self care and independent living• Enabling people • Evidence based

– Research and audit – User experience and views – Collaboration with health professionals, internal

and external

Results and Quality

• Outreach – 43% reduction in readmissions– Reduced admission into nursing or residential care– 70% improved breathing control

• Supported discharge– Median length of stay 4 days– 5% readmission rate– 8% length of stay 1 day

Phase 3 An Update for Kaiser

ElectiveCare

EmergencyCare

Chronic Disease

FamilyCare

DiagnosticServices

SupportServices

Teams &Facilities

2003 2005 2006 20072004 2008

Phase 1Old Payroll

8 admin staff

Phase 2Board Room

25 admin staff

Phase 3Balliol

45* staff

Phase 4Balliol + 12 Home Workers +

Diagnostic & Therapy satellites

Staff Care AdvisorsIT helpdesk

NT Auto Switch

SwitchboardRecruitment

Digital Dictation

Core outpatientsWLI inpatient listsPre-Op screening

Bed management

Choose & BookCapacity scheduling

GSUPP & CAPIO

PhysioLine

Gynae booking

Respiratory CRM Pilot

Choose & BookDiagnostics

50% InpatientBooking

EmergencyOutpatient

Appointments

NT outpatients

Pathway for18 week

target

Foundation CustomerRelationshipManagement

£20k £300k£120k

£0k -£100k£0k

CapitalCost

Revenue Cost ? ? ?

Contact Centre Development Plan

Core Contact Centre

• Now doing 15,000 calls per month

• Move to ‘proper’ contact centre this month– 50 seats (currently have 19)– Training and distribution facilities

• Integrating switchboard in April so we have 24/7 service and a one stop number for all services

Physio Line Contact Centre

• Currently patients wait up to 8 weeks for first appointment with physio

• New pilot with 4wte clinical staff (physios) on the phones

• Taking calls from musculoskeletal patients attending their GPs in Whitley Bay and Central locality

• Aim for full phone review by physio within 48 hours using e-tools created within trust

Physio Line Contact Centre

• Physio will assess patient and decide how to proceed…– Advise and discharge– Advise and follow up by phone– Book into appropriate appointment– Stream ‘red flags’ to appropriate location

• Aim to manage 60% patients without need for face to face appointments

• Full Northumbria roll out would take 10wte physios

• If all goes well we hope to extend Physio Line to other clinical professionals and specialties

Digital Dictation & Speech Recognition

• In Kaiser Atlanta we saw same day automated documentation production

• We have delays of up to 6 weeks and spend over £1million per year on typing alone

• We recognised the potential for us…

Digital Dictation & Speech Recognition

• We have appointed a supplier and commence pilot March 2005– Same day document production– Letters for patients while they wait– Discharge letters emailed to GPs same day– All hospital correspondence available electronically to

all staff

• Aspire to make 80% reduction in typing backlog and 40% efficiency savings

Care Facilitation- Use of Interqual

What is care facilitation ?

• Clinical Decision Support Software Introduced– Aim for the Right patient in right bed all of the

time with shortest hospital stay– Used software to tell us what beds we need

• Patients’ journey facilitated by teams of Care Facilitators

• Interqual used to check that patients are receiving the right level of care for their needs

• Software used to assess care needs on admission, continued stay and safe to discharge.

• Ensures that patients are not receiving to low or to high a level of care

Strengthening Back of House:Care Facilitation

Care Facilitation Admission Review Results

51%

26%

23%

Observation Acute Wrong

4.90%

18.70%

4.30%

46.30%

2.90%

2.90%

5.60%

10.10%

Acute Homecare Long Term Care Observation

Outpatients Residence Skilled Nursing Facility Skilled Therapy Facility

No ALOC Entered Critical Care (Intensive / Coronary) Intemediate (HDU)

N = 7,206

Of the total occupied days for the patients followed by care facilitators, most were at an

inappropriate level

0% 20% 40% 60% 80% 100%

Inapropriate use of acute bed day due to level of care not available

Inapropriate use of acute bed due to service delays

Appropriate use of acute bed

15,794 days

31,441 days

10,300 days

23507

24402

28049

58090

60274

65019

1455

1423

1395

21%

16%

4%

Admissions are up Outpatient Referrals are up

Beds are down Fewer Medical patients in surgical beds

As well as giving us data, Care Facilitation is enabling us to cope

What Interqual tells us we need to do…

• re-designate our hospital beds

• sort out timely diagnostic and therapy support

• actively medically review the sickest patients

• focus on levels of care for the avoidable admissions

What else are we interested in?

Culture, culture, cultureCustomer satisfaction matters – this requires personalised care & real choices

• Performance based on patient satisfaction– Behaviours are based on the organisational values– Used as part of recruitment process– 360 degree appraisal (team and patients)– Performance management

• Incentives and exit strategy– Process improvement

• Whole systems leadership & OD programs • Behaviours based on values

• Concentrating on the customer • Recruiting with the customer standards in mind and moulding people to be ‘our

people’• 360 degree involving patients

New

Ideas

Kaiser

Learnin

g

Kaiser

Learnin

g

Right

Direct

ion

Real information is key• Whole system health information used to allocate

resources

• Information is used as the basis for all decision making

• What we have done today, not last year

• Real time information about demand, capacity, activity, and backlog

Kaiser

Learnin

g

Kaiser

Learnin

g

Kaiser

Learnin

g

New

Ideas

What we would like from KP

• Skills for – using information, – moulding behaviours, – improving performance– changing the culture– Systems change

• Experience of KP people working with our teams– Medical staff using care facilitation– Support developing Integrated contact centre– Job swap or Shadowing equivalent Kaiser Staff eg Chief

Exec, Med Director, Senior Exec