katie roebuck, mcp programme manager · triage referral pathways non hub response specific person...
TRANSCRIPT
Wakefield’s Connecting Care Programme
Katie Roebuck, MCP Programme Manager
Overview
• Brief overview of Wakefield District• Connecting Care Hubs and evaluation• MCP Key Transformation Areas• Emergency and Urgent Care• Care Homes
Map of Wakefield
• To be added
Multispecialty community providers
moving specialist care out of hospitals into the community
Integrated primary and acute care systems
joining up GP, hospital, community and mental
health services
Acute care collaboration
local hospitals working together to enhance clinical
and financial viability
Enhanced health in care homes
offering older people better, joined up health, care and
rehabilitation services
Urgent and emergency care
new approaches to improve the coordination of services and
reduce pressure on A&E departments
Five new care models announced – Wakefield has 3/5
Programme Management & Governance
PMO
• Concluding the transition from West Wakefield and embedding new PMO arrangements within the Wakefield connecting Care team hosted by Wakefield CCG.
• PMO fully resourced and operational
Alliance Agreement & Governance
• 18 month Alliance Agreement to support work programmes of NMOC Board for “virtual” MCP arrangements is developed which has outcomes agreed by all partners across the system and is now signed by all partners.
• New governance structure in place, with the development of the New Models of Care Board & JODG Group.
Assurance Frameworks
• WMDC Public Health Team have developed at a project level detailed Physio, Pharmacy, Mental Health & Connecting Care frameworks, which align activity and finance more specific to cohorts.
• Care Home Assurance Framework and MCP Key Indicators framework have been developed.
Governance
MCP Vision
• “Creating person centred co-ordinated care” is the agreed Wakefield Vision which lies at the core of everything we strive to achieve working with our
partners in Connecting Care Health and the Social Care Partnership.
• The Multi-specialty Community Provider (MCP) model is about integration and removing historical barriers that
have prevented joined-up preventative patient care across primary, community, mental health, social care
and acute services.
MCP Outcomes framework
Connecting Care
To ensure our new model of care is delivering against an agreed series of indicators that support improved patient care across the health and social care system. Specific measures include:
Outcome 1: People can access information and advice that is clear, up to date and consistent
Outcome 2: Care and Support is responsive, timely and joined up
Outcome 3: Support is provided by caring, considerate people with right skills
Outcome 4: People live in safe and positive communities
Outcome 5: People are encouraged and supported to be healthy
Outcome 6: People are assured service and resources are efficient
Model of care- 8 key components for MCP Framework
“Through expanded community and primary care, proactive teamwork and new technology to deliver health and social care at scale to our residents of Wakefield and
our patients captured by our GP registered list”
Prevention Self CareCare
NavigationImproved
AccessSupport at
HomeAdmissions Avoidance
Early Supported Discharge
Connecting Care
Whole population prevention and
population health management
Urgent care needs –
integrated access and rapid response service
Ongoing care needs –
enhanced primary and
community care
Highest care needs –
coordinated community based and
inpatient care
Contract, commissioning
and funding
Flexible use of workforce and
estates
Building shared care records and
business intelligence
systems
Cultural and change
“What matters to me?”
Diagram: Connecting Care Hubs pathway Connecting Care Hubs Referral Pathways - Draft V:4 – 17.07.2017
GP
Ref
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ls
to C
C H
ubs
Wakefi
eld
On
e
Bu
llen
shaw
an
d W
ate
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n C
on
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ctin
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are
Hu
bs
Referrals to Social Care Direct (SCD) / MY Therapy &
Mid Yorks Single Point of Contact (SPOC)
GP Referrals direct to Connecting Care Hubs
Wakefield One
Triage Referral
pathways
Non Hub Response
SPECIFIC PERSON CONTACT /
OTHER SINGLE AGENCY REFERRAL (that is not based in the connecting care hubs).
Contact or referral passed to appropriate person /
agency to be actioned, then recorded & closed on
appropriate system
Non Hub Response
Bullenshaw / Waterton Connecting Care Hubs
Referrals received by Care Co-ordination Unit
Hub Referral Pathways
ROUTINE REFFERAL PATHWAY
Care Co-ordination Unit Actions:
Referral added to list for inputting / updating on
PIC and any other systems as appropriate
recording allocated team/person and
recommendations.
If ongoing local authority action needed, then
referral put on Care Director and allocated to
appropriate team.
INFORMATION / ADVICE /
SIGNPOSTING RESPONSE
Contact recorded & Closed on
appropriate system
Connecting Care Hub Response
URGENT REFFERAL PATHWAY
Care Co-ordination Unit Actions:
Verbally Make URT Team aware of referral.
Update/input PIC on other systems as
needed recording allocation and
recommendations.
If ongoing local authority action needed, then
referral put on Care Director and allocated to
appropriate team.
Routine Referrals
Urgent Referrals
TRIAGE BY HUB
DUTY MANAGERS
Recommended actions sent to Care Co-ordination
Unit to update PIC etc and allocate to appropriate
team as routine or
urgent referral
Referral received by allocated Connecting Care
Hub partner organisation / person and actioned.
PIC updated and lead worker assigned to co-
ordinate care plan if other services involve.
Referral received by allocated Connecting care
Hub partner organisation / person and actioned.
PIC updated and lead worker assigned to co-
ordinate care plan if other services involve.
Current Connecting Care Hub Partner Organisation Providing Hub Response
Social Care Direct / MY Therapy / Community Matrons / Age UK Wakefield / Wakefield Carers / Connecting Care Pharmacy / WDH / Mental Health Navigators
Connecting Care Hubs Communication to GP
This is Connecting Care…
(Link to Connecting Care overview)
Connecting Care Hubs: LA- WMDC Funding commitment to model
“ASC/ BCF Funding & Estates”
• Additional care co-ordination and social work staff, recruitedto multi-disciplinary team to enable 7 day locality working
£1.1 million
• Additional care co-ordination and social work capacity for Hub/ Hospital Interface to facilitate new “Discharge to Assess” arrangements
£260k
• 1/3 contribution to establishment of new unit of co-ordination support officers
£140k *WMDC contribution
• Estates and accommodation developments to provide modern facilities to deliver new ways of integrated working
£2.2 millionFunded from WMDC capital reserves
MCP key transformation areas to be delivered in 2017/18
Connecting Care
Resources have been secured from NHS England to support Wakefield District to roll out some key transformation projects during 2017/18. Eight of these transformation projects are integral to primary care and community care development and are outlined in Wakefield’s Delivering the General Practice Forward View The Wakefield 2020 General Practice Plan. These include:
• Integrated Nursing Teams• Primary Care Mental Health• Late Visiting Service• Developing a Wakefield Training Academy for
Primary Care• Increased access to pharmacy• Physio first/line
Progress to dateWakefield commissioners across system have over the last 2 years worked together to ensure that Wakefield has plans in place to fund the interventions that NHSE has funded across our system that have had impact. This is a summary of the progress to date:MCP VanguardThrough a series of commissioning reviews in WCCG and WMDC funding solutions are in place for the following areas of the model of care from April 2018:• Discharge to Assess (funded through WMDC iBCF resources that are available 3
years)• Late Visiting service (funded through decommissioning a historic LES for general
practice to fund this model across District from April 2018)• Physio in General Practice (funded through the community Physio funding
envelope within CCG from April 2018)• Pharmacy in General Practice- this detail still being worked through with
practices but likely to be a combination of top slice of prescribing budget and part contribution from general practices – CCG will confirm in q3 assurance meeting
Progress to dateWakefield commissioners across system have over the last 2 years worked together to ensure that Wakefield has plans in place to fund the interventions that NHSE has funded across our system that have had impact. This is a summary of the progress to date:MCP VanguardThrough a series of commissioning reviews in WCCG and WMDC funding solutions are in place for the following areas of the model of care from April 2018:• Care Navigation training and support for Wakefield practices- to be confirmed in
q3 assurance meeting but discussions with Conexus underway and this is likely to be provided from Conexus with no cost to Wakefield system from April 2018
• GP OOH access model (GP Care Wakefield)- funding is available from NHSE for this and NHSE NMOC team stopped funding this in year 2
• Carers Support and Age UK support to model of care- funding is available from the reduction of 78 to 26 inpatient beds in MYHT – this has been removed from MYHT community contract and transacted
Evaluation Headlines – MCP Key Indicators
Over 65 cohort established as those most likely to benefit from interventions
Activity compared to 2016/17 baseline (April – August 2017):
• 4.5% reduction in emergency admissions
• 2.4% reduction in ambulance conveyances
• 3.3% increase in A&E attendances
• 4.3% increase in emergency bed days
Evaluation Headline - Pharmacy
Savings generated May – Sept = £351,459.
Average of £258 saved per pharmacist intervention (1,360 interventions).
31% of patients had their treatment simplified.
17% of patients had a redundant item removed.
Evaluation Headline - Physio
Physio Line (Apr – Sept vs 2016/17 baseline)
– 41% reduction in first appointments to community physiotherapy
– 34% reduction in follow up appointments
Physio First
– 13% increase in first appointments
– 3% reduction in follow up appointments
Rest of the District
– 3% increase in first appointments in community physiotherapy service
– 7% reduction in follow up appointments
NHSE National Enhanced health in Care Homes Framework
Wakefield Model
27 care homes as part of the vanguard (mainly residential and nursing homes over 65`s)
Working with 27 GP practices (38 practices in Wakefield)
This equates to 1,594 active beds (total bed base for Wakefield 2435 active beds)
Plus 6 extra care facilities working in partnership with Wakefield District Housing and Wakefield Council
Evaluation Headlines – Care Homes
Phase one and two combined position YTD vs 2016/17 baseline
Emergency admissions: +1%
A&E attendances: +1%
Ambulance calls: +7%
Bed days: +0%
Phase one performing ahead of target in all except ambulance calls, Phase two not hitting target.
Unified primary and urgent care
NHS 111/999
GP Practices
Community pharmacy
Pharmacy in general practice
Enhanced services
Social prescribing
Information and advice
Assessment
Safeguarding
Homecare
Residential and nursing care
Connecting Care Hubs
Single point of contact
Social care
Voluntary sector navigators
GPs and consultantsMedical outreach
Integrated community health
care teams
Rapid response Late Visiting Service Ambulatory Emergency Care
Social Care
Urgent Care Treatment centre
Walk in centre
Primary care streaming
A & E
Hospital to home
Frailty units
Discharge
Outpatients
Unified secondary care response
Personal integrated file
Real time situational analysisGP Care (Extended access)
Clinical advice booking service
West hubFace to
face
Trinity Medical centre
East hubFace to
face
Same day access for routine care
Physiofirst/Physioline
Care Navigation
Appropriate referral of patients back into primary care via GP located within A & E
Integrated pathways to all services
WY Urgent Care OOH
Direct stroke service
Specialist services
Diagnostic access
Planned service provision
What have been the challenges?
• Multiple Providers each operating in their own silos– Separate teams
– Differing cultures / value systems
– Inclusion / exclusion criteria, Referral forms
– Poor information sharing, lack of IT and IS integration
– Lack of trust and mutual understanding
– Differing KPIs and targets
– Tendency to shunt problems around
– Gaps and overlaps
– Reactive not proactive
– Slow to respond
– Organisational hierarchies
– Lack of communications technology
– Focus on caseload and no situational awareness
– Struggling workforce
• Lacking clinical leadership on the ground
What we learned
- The source of most of the frustrations and anxiety have been the result of different messages and language. Getting the right message across to clinicians needs careful thought and planning.
- Things don’t always work – pharmacy first very low uptake.
- It takes time to build relationships and trust
- Without a properly positioned PMO or ‘engine’ room for delivery, an organisation will struggle to ensure action plans are delivered in line with expectations and at the pace required.
- Business As Usual (BAU) can take too much of the week up – capacity needs to be created in order to work more effectively on addressing the financial challenge.
Thank you