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