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Stockport Together – Neighbourhoods

- Stockport Together context- Proactive Care programme- Neighbourhoods

Introductions

Dr Ash Patel

Cheadle and Bramhall GP

Viaduct

Dr Sarah Griffiths

Four programmes

Proactive Care: Supporting people with long-term health conditions or social care needs to remain in their preferred location.

Improving access to support and increasing the quality of care for people.

Helping individuals to avoid the need for urgent (same-day) health or social care - e.g. reducing A&E admissions.

Prevention and Empowerment: Supporting people in taking steps to improve their own well-being. Increasing the number of people who understand their own health and social care needs.

Reduce people’s need to rely on health and social care services.

Planned Care: Working with people who have a known need and require on-going access to services.

Reducing unnecessary outpatient attendances and GP referrals by working to better understand patient needs.

Maximising the use of technology to improve patient experience.

Urgent Care: Providing access to people needing urgent, same-day care.

Improving the way people who require urgent access to care are assessed, stabilised and discharged.

Helping to stabilise people as soon as possible and to improve their experience and outcomes.

Five components

Specialist Response

PL4. Zone 4- Specialist services including urgent access to planned care

Optimising health and well-being

PRE1. Population - Identifying risks and empowering change

PRO1.1. Finding people early

PRO1.2. Prevention where there is a known need

PL1. ZONE 1: Self help advice

PRE5. Wider determinants of health

Primary Response

PL2. Zone 2- Primary care services

PL3. Zone 3- Primary care with specialist advice

PRO3.1. Support to people with LTCs

UC3.2. Non-Urgent Care Hub

PRE4. Services – Prevention embedded in every pathway supported by IT

Urgent Stabilisation Response

PRO4.1. Crisis response

UC1. Single point of access (SPA) and virtual admission assessment

UC2. Initial assessment service (face-to-face)

UC3.1. Urgent Care Hub

PRO3.3. Strategic design of Neighbourhood Teams

PRO3.4. Intermediate Tier redesign

PRO3.4. Strategic design of Locality Teams

PRO3.2. Complex Care

PRO4.2. Recovery response

UC3.3. Integrated discharge teams

Proactive Response

Design Components

6

Proactive care principles

• One person manages/coordinates • One care plan• Using one record• Person centred • Person empowered to Self Care• Supported by an empowered community• No plan concerning me without me• Support 7 days a week• Care provided proactively to reduce crisis• People found to enter treatment• Care managed as a team with no referrals

Background – Neighbourhood Service

• Delivering to neighbourhoods of circa 30 – 50k GP registered populations

• 8 neighbourhoods across borough

Neighbourhood Service delivered by:• GP federations – GPs and practice staff• Integrated Neighbourhood Team – nursing, social

care, allied health professionals, business support• Aligned third sector, Pharmacists• Mental health services and alignment TBC

Flexible team

Federated GP Vehicle

GP Practice

GP Practice

GP Practice

GP Practice

MDT

Streamlined referral

Clinical risk and accountability Service delivery

Integrated Neighbourhood Team (x8 teams)

Structure of Integrated neighbourhood Service—Early Adopter Cheadle and Bramhall, October 15

Multidisciplinary Neighbourhood Team Manager Band 7/MB4

Social WorkersSO2

Social Care OfficersSC5/6

Health Assistant Practitioner

Band 4

Business Support

Health Care Assistant Band 3

District NursesBand 6

Social Care ATMSO3

Registered NursesBand 5

Targeted Prevention Alliance

Advanced nurse practitioner

clinical lead facilitator

Medicines Management

Mental Health (TBC)

REaCH

Unregistered Health Care Staff

OTs SO2

Joint care planning

case finding

Information sharing

Finalise scope, model & funding

Operational co- design of neighbourhood team model

Go live: Early Adopters . Extended operating hours, proactive model, shared functions, neighbourhood service

June July Aug Sept Oct April 2015 2016

Go live: pan- borough co-located multi-disciplinary Neighbourhood Teams

Phase 1 Enabler Implementation – Accommodation, IM&T, Communication, Workforce Development, HR

Go live cross borough - full

model

Co- design of local approaches and systems

Phase 2 Enabler Implementation –IM&T, Communication, Workforce Development, HR

Neighbourhood Service Roll Out Timeline

Respond to wider Proactive work to deliver at neighbourhood and locality level – extend scope, model, and funding allocation

GP Practice co- design of federated model

Go live: GP federated model in Cheadle and Bramhall

Targeted Prevention Alliance go live and design

Neighbourhood Teams Implementation

For October 2015, 3 levels of implementation:

1. Early Adopter - Cheadle and Bramhall – aligning the Neighbourhood Team to the Federated GP Vehicle

2. Early Adopter - Marple and Werneth - aligning the Neighbourhood Team to separate GP Practices

3. Integrated, co-located Neighbourhood Teams operating across Stockport

Neighbourhood Approach

Development phases

Core teamGPs , DNs, SWs

Core teamPlus 3rd sector

Core teamPlus 3rd sectorMental Health

Core team Plus 3rd sector, Mental Health, Therapy, Intermediate tier

Full new Out of hospital service with prevention, planned and urgent links

Plan Do

Study Act

Plan Do

Study Act

Plan Do

Study Act

Plan Do

Study Act

Plan Do

Study Act

Integrated Neighbourhood Teams

• 8 x integrated multi-disciplinary Neighbourhood Teams– Circa 30 staff including nursing, social care, allied health

professionals, business support

• Multi disciplinary line management• Co-location• Information-sharing agreements• Information technology• Relationship-building with broader partners in local area• Workforce development to build skills and team identity

Early Adopter: Proactive Model

Cheadle and Bramhall Early Adopter Key Deliverables

• Proactive case identification and management• Aim for no formal referrals within Neighbourhood Service • Holistic, joint assessments and care and support planning,

with specialist assessments added where required:– Motivational and promote resilience and self-reliance – Incorporate contingency and deterioration planning– Make best use of community assets and innovative

solutions• Multi-disciplinary triage and crisis response offer delivered

at neighbourhood level - scale to be defined• Case co-ordination delivered by all team disciplines

Cheadle and Bramhall Early Adopter Key Deliverables cont..

• Extended operating hours to cover evenings and weekends• Delivery aligned with wider neighbourhood and locality service

(GP Practices, third sector, intermediate tier etc.)• Systems to enable joint working with wider partners on most

complex cases• Community management of deterioration, where possible• Rapid access to specialist services for assessment and

intervention when needed• Clear pathways between urgent care and neighbourhood

service

Key challenges

• Cultural change – shift from reactive to proactive, silos to collaboration

• Estates to enable co-location• IM&T including network access and information sharing• Operational capacity to participate in co-design and

change process• ‘New world’ of federated GP model

Work streams

1. Establishment of core neighbourhood teams– Oct 15 first 2 others by 31st March

2. Review of other services three phases– borough wide services– To join the core team

3. Intermediate tier service review options in August

4. Care homes realignment and support – in progress

5. Targeted prevention - new service started July

6. Prevention, planned and urgent care requirements - October

7. Organisational form