Post on 21-Oct-2014
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Community Services – Beyond Transfer to Transform
Acute and Community Services “Integrators of Care”
Linda Watson, Clinical Director of Community ServicesCarole Langrick, Deputy Chief Executive/Director of Strategic Development
Community Services – Beyond Transfer to Transform
Presentation will cover:
• Who we are
• What we did and why in relation to vertical integration
• Outline the progress in 6 key areas of integration
• Illustrate the ways in which our model has enhanced patient care
Who are we?
• Provide healthcare to 400,000 people in Easington, Stockton, Hartlepool and Sedgefield
• Foundation Trust since December 2007
• Have two major hospital sites in Stockton and Hartlepool
• Work from 38 community sites
• Employ 5,500 staff including 1200 in community services
• Have a £230m annual budget
Community Services – Beyond Transfer to Transform
Why did we do it?
Community Services – Beyond Transfer to Transform
Community Services – Beyond Transfer to Transform
What did we do?
• PCTs transferred community services to the Foundation Trust on 1st November 2008
• Contract extended to June 2011
• Underpinned by legal agreements
• TUPE transfer for staff
• PCTs retained premises and assets
• Foundation Trust to maintain services, staff and all other arrangements throughout duration as they were at point of transfer
Community Services – Beyond Transfer to Transform
• Currently 60% of patients die in hospital, 20% at home, 15% in care homes, 5% in Hospice
• Future 60% would prefer to die at home• Would you be surprised?• 24/7 1 hour responsive care• GSF for Care homes• Information exchange• Advance decisions to refuse treatment• Prognosis to bereavement
Transforming Services: End of Life Care
Community Services – Beyond Transfer to Transform
Current State
• Multiple locations across Hartlepool and Stockton
• Two different service models
• No standard referral criteria
• Education provision is disjointed
• Disjointed communication
• Limited peer support
• Good relationships with generalist health and social care staff
Community Macmillan Nurses x 2,
Macmillan Secretary x 1 (P/T) Phoenix Centre
Community Macmillan Nurses x 2,
Macmillan Secretary x 1 (P/T) Phoenix Centre
ReferralsReferrals
Strategic meetingsStrategic meetings
Consultant in Palliative Care x 1, Macmillan Nurse
x 1 Secretary (P/T)
UHH
Consultant in Palliative Care x 1, Macmillan Nurse
x 1 Secretary (P/T)
UHH
Macmillan OT x 1, Macmillan Physiotherapist x 1, Palliative Care OT x 1
Hartlepool Hospice
Macmillan OT x 1, Macmillan Physiotherapist x 1, Palliative Care OT x 1
Hartlepool Hospice
EducationEducation
AuditAudit
Community Macmillan Nurse x 1
Masefield Road
Community Macmillan Nurse x 1
Masefield Road
Community Macmillan Nurse x 1
Masefield Road
Community Macmillan Nurse x 1
Masefield Road
Strategic meetingsStrategic meetings
Strategic meetingsStrategic meetings
Strategic meetingsStrategic meetings
Strategic meetingsStrategic meetings
Strategic meetingsStrategic meetings
ReferralsReferrals
ReferralsReferrals
ReferralsReferrals
ReferralsReferrals
ReferralsReferrals
ReferralsReferrals
AuditAuditAuditAudit
AuditAudit
EducationEducation
EducationEducation
Macmillan OT x 1, Macmillan Physiotherapist x 1, Macmillan OT Technician x 1 Lawson Street
Stockton
Macmillan OT x 1, Macmillan Physiotherapist x 1, Macmillan OT Technician x 1 Lawson Street
Stockton
Community Macmillan Nurse x 1, Billingham Health Centre
Community Macmillan Nurse x 1, Billingham Health Centre
Consultant in Palliative Care x 1, Nurse Consultant in Cancer and
Palliative Care Macmillan Nurse x 1
Secretary x 1 (P/T) UHNT
Consultant in Palliative Care x 1, Nurse Consultant in Cancer and
Palliative Care Macmillan Nurse x 1
Secretary x 1 (P/T) UHNT
Community Macmillan Nurse x 1
Eaglescliffe
Community Macmillan Nurse x 1
Eaglescliffe
Community Macmillan Nurse x 1,
Stockton
Community Macmillan Nurse x 1,
Stockton
Community Macmillan Social Worker x 1, Billingham
Council Offices
Community Macmillan Social Worker x 1, Billingham
Council Offices
ReferralsReferrals
ReferralsReferrals
Strategic meetingsStrategic meetings
Strategic meetingsStrategic meetings
ReferralsReferrals
AuditAuditAuditAudit
EducationEducation
EducationEducation
Macmillan CNS Referrals
Macmillan CNS Referrals
AuditAudit
ReferralsReferrals
Service development
Service development
Service development
Service development
Service development
Service development
Service development
Service development
Clinical supervisionClinical supervision
Clinical supervisionClinical supervision
Hartlepool Consultant in Palliative Care x 1, Macmillan Nurse x 1 Secretary (P/T) Community Macmillan Nurses x 3, Macmillan Nurse
for care homes x 1 Macmillan OT x
1, Macmillan Physiotherapist x 1,
Palliative Care OT x 1 Secretary x 1 (P/T)
Hartlepool Consultant in Palliative Care x 1, Macmillan Nurse x 1 Secretary (P/T) Community Macmillan Nurses x 3, Macmillan Nurse
for care homes x 1 Macmillan OT x
1, Macmillan Physiotherapist x 1,
Palliative Care OT x 1 Secretary x 1 (P/T)
Strategic meetingsStrategic meetings ReferralsReferrals
Audit/ResearchAudit/Research
EducationEducation
North Tees Consultant in Palliative Care x 1, Nurse Consultant in Cancer
and Palliative Care x 1 Macmillan Nurse x 1 Secretary x 1 (P/T) Community Macmillan
Nurse x 3, Palliative Care Nurse for Care Homes x 1 Macmillan OT x 1, Macmillan Physiotherapist
x 1, Macmillan OT Technician x 1 Community Macmillan
Social Worker x 1,
North Tees Consultant in Palliative Care x 1, Nurse Consultant in Cancer
and Palliative Care x 1 Macmillan Nurse x 1 Secretary x 1 (P/T) Community Macmillan
Nurse x 3, Palliative Care Nurse for Care Homes x 1 Macmillan OT x 1, Macmillan Physiotherapist
x 1, Macmillan OT Technician x 1 Community Macmillan
Social Worker x 1,
ReferralsReferralsStrategic meetingsStrategic meetings
ReferralsReferrals
EducationEducation
ReferralsReferrals
Service development
Service development
Clinical supervisionClinical supervision
Audit/ResearchAudit/Research
EducationEducation
New SPC team structure
Service Delivery Expectations
Community Services – Beyond Transfer to Transform
• 100% of people who identify their preferred place of care will achieve that aim, where clinically appropriate and family are involved
• 100% of people requiring specialist palliative inpatient care where appropriate, will receive it
• 100% of carers requiring access to appropriate support will receive it
• 100% of carers will have their bereavement support needs assessed and will be signposted to appropriate support
• 100% of people dying in the hospital setting will have their end of life needs assessed and addressed
Transforming services: Intermediate Care and Reablement
• Creative whole systems pathways of care and support
• Excellent interagency partnership working – but can improve
Community Services – Beyond Transfer to Transform
Intermediate Care and ReablementCurrent State
IntermediateCare
Rapid Response
Community Stroke
Falls Team
OT’sPhysiotherapy
AssistantsReablement
workers
Rapid response
NurseHCA’s
OTsPhysiotherapy
SLTDietician
PsychologyAssistants
CoordinatorOT’s
PhysiotherapyAssistants
Emergency Care Therapy and Acute Teams and RASWS
Community Services – Beyond Transfer to Transform
Transforming Services: MSK Services
• Further integration
• Step change reduction in GP referrals to Orthopaedics
• Higher surgical conversion rates when referred on by MSK service
• Health economy savings realised
Community Services – Beyond Transfer to Transform
The Purpose of the Managed Care Team
• To use the Community Virtual Ward concept to ensure that there is a philosophy and culture of sustained improvements and innovation to deliver savings through improved care for patients with LTC, the frail
elderly and those at risk of readmission within 30 days.
• To act as a co-ordinating group to ensure that patients receive efficient and
productive services that enhances both the quality and safety of care.
• To ensure a systematic approach for patients who are ‘at risk’ of admission and readmission to hospital across North of Tees.
Community Services – Beyond Transfer to Transform
Transforming Services: Community Virtual Ward
• Prevention of preventable admissions
• Reduced LOS by improved discharge planning
• Increase preferred place of care for patients with LTC to actively manage their condition
• Development of integrated pathways across provider services
• Appropriately trained workforce to deliver the right care in the right place at the right time
• Improved evidence based outcomes for patients and staff
• Provision of alternative cost effective solutions to healthcare delivery
Community Services – Beyond Transfer to Transform
Anticipated Outcomes
Community Virtual Ward – Managed Care Pathway
Managed Care Team
(Single Point of Contact 24/7)
Rapid Response, CM’S, DN’S, MDT, SOCIAL CARE (Primary Resources)
GP Practices
Acute Community Medical Support
IT
PCS
Audit
• Patients triaged for suitability for Virtual
Ward admission. • Patients contacted by letter to offer services• Care plan developed following assessment.• Patients discharged to appropriate service
following period of care under managed care team
Outcomes; improved quality, patient satisfactionavoidance to hospital, reduced admissions
Patients identified using PARR ++ GP Practice to gain consent from patient to refer for Managed Care
Supporting Departments
Intermediate Care
Specialist Nursing
Tele-health
Pharmacy
NEAS
Secondary care services
Business Support
Departments
Admin
Training
Transforming Services: Improved Quality
• Peer review to measure quality
• Senior nurses from primary & secondary care undertake reviews – never in their own area
• QRP undertaken in health centres, community clinics and patient’s own homes
• Results of QRP are reported to Trust Board
Community Services – Beyond Transfer to Transform
Transforming Services: Staff Experience
• Infection Control – More robust protocols and checks and monthly audit control measures in our community clinics.Stop Smoking Service
• Networking between Acute and Community which improves working relationships and understanding of each others role. Opportunities for secondments to other areas.District Nursing
• I think altogether, we are settling into Community Service very well and we are all happy and proud to work for the FT. We certainly ‘fit’ better into the FT than the PCT as it now stands.Health Trainer
Community Services – Beyond Transfer to Transform
Community Services – Beyond Transfer to Transform
Thank you