stockport together – neighbourhoods -stockport together context -proactive care programme...
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Stockport Together – Neighbourhoods
- Stockport Together context- Proactive Care programme- Neighbourhoods
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.
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
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
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