Better care, closer to home Our strategy for high quality care - - PowerPoint PPT Presentation
Better care, closer to home Our strategy for high quality care Draft document March, 2011 0 1 Changing health needs are placing increasing pressure on health and social care Hounslows health trends Area of relatively high population
March, 2011 Draft document
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SOURCE: JSNA, CSP submission
Hounslow’s health trends
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IV Community Matrons ART and social work District Nursing Community Rehab Mental health Different services work separately Resulting in patients falling though gaps After being stabilised by great care from the ICRS Ms Smith was readmitted after she was passed to core services Inexperienced district nurses refer many patients to GPs unnecessarily Many stroke patients are confused about who is co-ordinating their care after they are discharged Hospital is unable to discharge early because they don’t trust services to coordinate
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SOURCE: HES 10/11 (First 8 months)
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SOURCE: GWCC Commissioning Strategy 2012/13 – 2014/15
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A joined a system of care… 2 Simplified planned care pathways to enable local/self management 3 Rapid response to urgent needs sign posting patients to the best service 4 Providers working together to effectively manage the elderly and LTCs out-of-hospital so patients feel secure and receive seamless care 5 Appropriate time in hospital when admitted, with timely supported discharge to well supported community care 1 Patient has easy access to high quality, responsive primary care A single point of access means patients go directly to the most appropriate service 2 3 4 1 General practice Hospital Care Acute hospital at home care Planned care Health and social care teams Urgent care 5
6 SOURCE: GWCCG Commissioning Strategy 2012/13 – 2014/15
Easy access to high quality, responsive primary care through continuous drive to improve performance and access and reduce inappropriate variation led by education and peer pressure with performance management when necessary. To seek to develop Heston Health Centre and a primary care facility on the WMUH site. High quality elective care and well understood planned care pathways with minimal numbers of attendances at secondary care to reduce the time patients have to take from their daily lives, detailed care and management plans sent to GPs and patients to enable local/self management. Rapid response to urgent needs so that fewer patients need to access hospital emergency care. Telephone first – patients to know that this is the best way to good signposting to an efficient and seamless service. Patient education on how to get best value from their NHS. Palliative care to move to an elective service. Providers (social and health) working together, with the patient at the centre to proactively manage LTCs, the elderly and end of lifecare out-of hospital., resulting in patients feeling secure in referral into an effective and safe partnership between the community providers, social services with support from their GPs
Appropriate time in hospital when admitted, with early supported discharge into well organised community care
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Claire is 36. She is a working mother who struggles to manage her work and home life. She has a young son, Jason who is 4 years old and has a fever. Claire understands that 111 can direct her to the most appropriate care She is relieved and reassured, feeling confidence in the system Claire is reassured and feels confident to see episode through Record is taken of the event and communicated to the family’s GP via SystmOne In future, patients will have better access to primary care and know how to get it . . . Primary care has been difficult for some patients to access, putting pressure on other parts of the health system… Stressful and time consuming process for Claire to find a solution A&E staff feel overwhelmed by flow of unscheduled patients Claire grateful for treatment and idea of A&E as place to get care is reinforced Claire uncertain what best course of action is and who to contact Claire comes home form work at 6pm to find her son has come back from nursery with a fever Claire rings her GP but cannot get through. After several attempts decides to take Jason to her local A&E A&E is crowded and there is long wait. The conditions are stressful and Jason’s condition worsens. Treatment is transactional. Jason misses out on opportunity for broader child welfare e.g., staff do not make sure jabs up to date, check Claire is coping GP sees her son and has access to child's (and family's) health record, they check child over, look for rash and send home. They send record
If it was something more serious (e.g. rash with query meningitis, then the GP could have given a injection of penicillin before sending on to paeds unit) She is given an appointment for 8,30pm at the Urgent Care Centre to see a GP Claire comes home form work at 6pm to find her son has come back from nursery with a fever and calls 111
8 Paul is 43. He is in good health but has been experiencing severe discomfort in his knee following a recent bout of exercise
Sometimes the pathway to receive planned care is complex and disjointed… Paul meets with his GP who is unsure of best treatment
to diagnose Paul is referred to an OP clinic for a scan After 2 weeks Paul is called in for a follow up appointment and receives 2nd scan and is advised he needs a hospital appointment 2 weeks later Paul has not received a followup and returns to GP for further advice In future, the pathway with be simpler, understood by all clinicians and joined up. . . Paul feels immediate progress is being made and information is efficiently passed between GP and consultant Paul is reassured by the structured approach His GP is able to check in on Paul’s progress with rehab Paul goes to hospital 2 weeks later for operation. He has a brief stay on the ward and is discharged with a rehab plan On arriving home receives an email from the hospital explaining plans for rehab and treatment plan is recorded in GP records via SystmOne MSK specialist physio carries out assessment, including a scan at the diagnostic clinic and books Paul a hospital admission and discharge date. Treatment is recorded in GP records via SystmOne. Paul meets with GP who discusses
treatment and impact. Books patient for MSK assessment with community services
Paul still does not understand what his treatment options are Paul has to take time off work to attend Paul does not have his results with him and his GP is unable to give further advice
9 Urgent care has been stressful when patients need support . . .
Ethan is 84. He lives alone and usually stable Parkinson’s disease and walks with a stick. Recently he has developed an urinary tract infection which has led to him becoming confused Ethan’s wife is worried and calls an ambulance In A&E, the strange surroundings make Ethan even more confused and he becomes disruptive and aggressive While struggling, Ethan rolls out of bed and severely hurts his leg Three weeks later, Ethan is still in hospital and his mental state has deteriorated, he is discharged into a care home In future, we will meet patients’ needs at home . . . Ethan is able to stay at home. His wife knows who is responsible for coordinating care Stress is minimised and the people with the most appropriate skills are available Early intensive support accelerates recovery A smooth transition is made to a locally based multi- disciplinary care team Days 1 to 4 – cared for in bed with regular visits from nurses in the team Day 5 – confusion much
and drinking well and wants to get
Day 5 onwards – physio working with carers increasing patient’s mobility and exercise tolerance GP, social worker and physiotherapist from ICRS visit Ethan at home. They review his medication, move the furniture in his lounge and set up a hospital bed and pressure-relieving equipment Ethan is referred to ICRS by his GP. He has been unable to get out of his chair for the past few
caring for him Day 7 – Referred to community rehabilitation service
Hospital nurse are not sure how to deal with him, causing them stress Ethan becomes more dependent on care and regaining independence is unlikely
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These standards will set our aspirations for the future …
They emphasize the central role
delivery of out of hospital care
They intentionally go beyond the current minimum contractual requirements of the GP contract
They are designed to address core primary care delivered by GP practices and broader set of care delivery outside of hospital
They aim to shift care delivery from more reactive unplanned care to more proactive planned care The standards are covered in four key domains
Individuals will be provided with up-to-date, evidence-based and accessible information to support them in taking personal responsibility when making decisions about their own health, care and wellbeing
Out-of-hospital care operates as a seven day a week service. Community health and care services will be accessible, understandable, effective and tailored to meet local needs.
Service access arrangements will include face-to-face, telephone, email, SMS texting and video consultation.
Individuals using community health and care will experience coordinated, seamless and integrated services using evidence-based care pathways, case management and personalised care planning.
Effective care planning and preventative care will anticipate and avoid deterioration of conditions
With an individual's consent, relevant parts of their health and social care record will be shared between care providers.
Monitoring will identify any changing needs so that care plans can be reviewed and updated by agreement. By 2015, all patients to have
SOURCE: Out of Hospital Standards sent to Clinical Board 1 March 2012
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Key issues faced by GWCC and measures in place to solve them
General practice Hospital care Acute hospital at home care Planned care Health and social care teams Urgent care Responsive emergency care
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Too many people going to A&E
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Admission to hospital when care could be better at home C Support at discharge
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Lack of support for patients leading hospital
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Lack of coordination between community services E High quality planned care
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Inconsistent referral patterns
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Lack of options out of hospital B Providers working together D
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Care for LTCs more reactive than proactive
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Lack of coordination between
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community services Access to Primary Care
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Poor access to GP
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Patients entering system in wrong place
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Inappropriate A&E attendances A
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We are developing primary care by supporting GPs to improve access, improving education opportunities for clinicians, increasing GP access to consultants and increasing accountability for access and quality
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A joined up system of 111, out of hours provision and the urgent care centre will direct patients to the right place in the system first time and stop inappropriate A&E attendances Our vision Easy access to high quality, responsive primary care Initiatives to deliver our vision A1 A2
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The Integrated Community Response Service has been running since June 2011, supporting patients go home from A&E and wards
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Ambulatory Care in the Community is a new service led by a consultant from WMUH to provide care needing consultant supervision in the community
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A joint rehabilitation and reablement team will provide multi- disciplinary care at home for longer spells than the current service Rapid response to urgent needs so more people can be cared for at home C1 C2 Issue we faced
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Poor access to GP
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Patients entering system in wrong place
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Inappropriate A&E attendances Access to Primary Care
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Too many people going to A&E
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Admission to hospital when care could be better at home Responsive emergency care C3 A
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Our Referral Facilitation System is creating consistent planned care: 29 Hounslow GPs triage patients and ensure patients get straight to the right place for them
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Consultants in the community are providing clinical leadership, inputting into care of individual patients and seeing patients in the community themselves Clearly understood planned care pathways that patients have confidence in B1 B2
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Inconsistent referral patterns
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Lack of options out of hospital High quality planned care B C
Shifting settings of care in mental health?
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Integrated care– to proactively manage long term conditions and other at risk groups
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The Integrated Community Response Service and the joint rehabilitation and re-ablement team will create a more continuous transition from hospital to home Supported discharge into well
community care
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SystmOne already enables more informed clinical decision making by letting GPs, the UCC view the same records: in future this will play a greater role in integrating care from all providers
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Our end of life care programme is already supporting more people remain in their place of choice
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Risk stratification, care planning and case conferences will increase the coherency of care and empower patients and carers
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Care navigators will play a new role, supporting patients and joining up health and social care
D2 E1
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Care for LTCs more reactive than proactive
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Lack of coordination between
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community services
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Lack of support for patients leading hospital
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Lack of coordination between community services
Providers working together Support at discharge D3 D4
D E
Care for patients with LTCs and mental health needs Acute psychiatric liaison
Issue we faced Our vision
D1
Initiatives to deliver our vision
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All non-emergency calls out-of-surgery hours, made to 111
Patients who may need a home visit, referred to out-of- hours service
Some patients given advice on phone
Others seen at home by GP
Patients seen without a wait because they have booked an appointment
Their attendance recorded on their GP clinical system through SystmOne
Operators provide direct advice to some patients 111 Out-of-hours service UCC
Patients needing an appointment, but not a home visit, booked into UCC
Support for non-emergency patients out of hours
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Clinical Networks are groups of local experts in a disease area, which includes consultants, GPs, patients and carers. Clinical networks currently exist for diabetes…
Non-medical as well as medical consultants play a key role, e.g., consultant social worker for dementia and consultant nurse in learning disabilities Consultant roles in
Ensure consistency and standards across the system
Provide leadership for clinical networks
Develop pathways for care
Provide guidance to clinicians
Provide clinical leadership on new developments in a disease area, such as new drugs Provide direct care for patients
Provide treatment for patients in community clinics
For example, we have a new consultant led community opthalmology service How they will do this Provide input into the care of individual patients
Advise other clinicians on treatment by phone or email
For example, mental health consultants are available from 12-2 to take calls from GPs on cases
Discuss cases at case conferences as part of multi- disciplinary groups: this will give experts from different fields the opportunity to input on a case
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Develop GP leadership within Hounslow Develop our professionals and our
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Monthly dashboard showing performance and targets
Process for holding ourselves to account for these targets Agree on how we will be governed 3
Unified IT systems providing shared records leading to better patient care and transparency on performance Put in place the right information tools 4
Involve, consult and inform patients and carers Engage patients and carers 1
Align contracts and incentives of all providers, to ensure system-wide coherence of behaviour and spend Develop the right contracts and incentives 5
Requirements To be successful we need to…
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Our commitment How we’ll deliver
We’ll create a patient engagement group, including GPs and practice managers will drive change
We’ll ensure that each locality will have a patient group
We will pilot an online consultation forum
We will hold events to consult on key issues, such as commissioning intentions and our Out of Hospital strategy, working in partnership with LINk (Health Watch) and other patient, user and carer groups
You’ll be consulted
We’ll set out the standards we are aiming for and report to you how the CCG, localities and individual practices / care providers are performing against them
We’ll explain what is changing, why it is changing, and how your input shaped decisions
You’ll be informed
You’ll be involved
The HCCG Board will have 2 patient representatives and meet in public
All local clinical networks will have a patient or public representative
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GPs input case details into SystmOne RFS Referrals follow precisely defined pathways Granular reporting on referrals to GPs and mentoring cells GPs
Diagnose and prescribe Consultants
Advise and treat Acute/mental health
Treat Care is visible to GP and prompts are given for follow-up actions GP risk stratifies patients Care plan in place and shared Regular check ups and early intervention Real-time shared records inform providers 1 Planned care becomes more consistent 2 Urgent care becomes better informed 3 Long term care becomes more pro-active 4 All information input by GP is visible to staff at UCC GP UCC Community
Maintain