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@KMHealthandcare #KMconf2017 ww.slido.com #KMconf2017
Encompass Multispeciality Community Provider Dr John Ribchester, - - PowerPoint PPT Presentation
Encompass Multispeciality Community Provider Dr John Ribchester, - - PowerPoint PPT Presentation
Encompass Multispeciality Community Provider Dr John Ribchester, Chair and Clinical Lead, Encompass @KMHealthandcare #KMconf2017 ww.slido.com #KMconf2017 Encompass Multi-Specialty Community Provider (MCP) Partnership New models of care 31
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2 Faversham practices 31,143 2 Whitstable practices 38,574 3 Canterbury N practices – 41,612 3 Sandwich & Ash practices – 17,444 3 Canterbury S practices – 46,632
Five CHOCs – 175,405 patients
Community Hub Operating Centres (CHOCs)
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Encompass MCP Journey
Ramping the pace Refining
- ur model
Integrated Case Management
Encompass Alliance Accountable Care Partnerships Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 October 2017 April 2017 April to September 2017 November 2016 to March 2017 August to October 2016 Ramp up of model at scale and pace Refinement and development
- f whole
model Embedding the value proposition and 10 week proof of concept Development
- f the formal
alliance with partner
- rganisations
Becoming an Integrated Accountable Care Partnership
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Integrated case management Health condition management Supported self-care Our approach to each of the population segments
Registered populations
Acute expenditure on emergency admissions
New models of care
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This builds relationships between health and social care professionals, improves health and wellbeing outcomes and enables multi-disciplinary team (MDT) working. They are identified through a combination
- f risk stratification and clinical judgement.
For individuals at high risk of future emergency admission to hospital. Patients may have one or more of these indicators:
- Complex co-morbidities
- Over 75s
- At risk of admissions to A&E in next six months.
- Increasingly dependent on the health and care
system.
- The patient has underlying social and wellbeing
needs not being addressed .
Our approach
Integrated case management
Agreed with patient/carer
Care plan
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CHOC core team includes:
Mental Health worker GP Health and social care coordinator Community nurse / LTC Nurse Pharmacist Geriatrician Social Prescribing Administrator Nurse Specialist Allied Health Professional
Additional members which vary locally:
Fire and rescue Police Acute specialists Integrated Discharge Team
Clinical Services
Our Integrated Case Management (ICM) Approach
Agreed with patient/carer
Care plan Social Care representative / social worker
Our workforce
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We want to support and empower people who have long-term physical and mental health conditions to keep people well and avoid hospital admission.
Health condition management
Moving some services, historically provided in a hospital, into the community, extending roles of GPs and other healthcare professionals. Provision of specialist clinics in a community setting, priority for cardiology, respiratory/pneumonia, rheumatology and frailty. Providing fast access to services in the community to avoid attendance at A&E. Fourth Catheter Service
- pened
in June 2017 Making sure mental health is given the same level importance as physical health.
Dementia support worker in place Group psycho-education showing positive results
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The aim:
- building strong social networks
- exercising more
- eating more healthily
- feeling more supported and in control of lives
- reduction in healthcare interventions for patients
identified with a social prescribing need
Supporting people to make healthier lifestyle choices to avoid preventable diseases.
Supported self care
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Helping people make informed decisions about their health
Social prescribing gaining real momentum in year three Health trainers roll out across all CHOCs
An initiative in schools to keep children active
Supported self care
Waitless Live MIU and A&E waiting times in east Kent Health Help Now Symptom advice and guidance on treatment
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24.7%
Catheter related admissions
5.7%
Emergency admissions
27.3%
Short stay admissions
5.8%
A&E minor attendance
What our patients said
‘First time in years I feel confident enough to go
- utside and hang my
washing on the line.’ ‘I have gained a lot of insight about a condition I have had for 17 years.’ ‘I’m more confident and independent. It’s changed my life.’ “This app is so good. I broke my leg and needed it checked immediately and it told me what hospital had quicker service and how long it will be to wait – excellent”.
£3.4m
planned model forecast 2017/18 net savings
Activity deflections
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‘Working within the CHOC MDT has improved delivery of person centred care. CHOC facilitates improved working relationships between health, social care and the voluntary sector and identifies gaps in a patient’s pathway that can lead to potential crisis. This is a meeting where all voices are heard, with no hierarchy. CHOC meetings are not only about meeting patient need and responding proactively, they are also a useful forum for sharing best practice, discussing potential outcomes and evaluating pathways of care. They are indeed a weekly highlight and I look forward to being part of its on-going evolution.’ Long Term Conditions Lead Nurse
‘Hats off to you, really good meeting and really good progress.’ New Care Models Programme Director NHS England Sheila O’Riordan Consultant Geriatrician tells us how she loves social prescribing #way ahead @RedZebraCommSol @FutureNHS @NHSImprovement
And others…
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Strategic development
- Kent and Medway ST
- East Kent
- Encompass and NHS Canterbury
and Coastal CCG
- Strategic and operational alliance
Replicability and spread
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Contact us
Dr John Ribchester – Encompass Chair and Clinical Lead john.ribchester@nhs.net Cathy Bellman – Strategic Project Manager cathy.bellman@nhs.net