Integrated Services

Dr Steve Cartwright – Clinical Executive for Integration and Partnerships

Andrew Hindle - Commissioning Manager for Integration

Dudley CCG: context

CCG registered population = 312,000 47 practices 10 single handed practices Mixture of wards including some in the lowest

20% for most deprived across the country and some in the top 20% of most affluent.

Dudley Health and Social Care Economy – The Opportunity

Unnecessary emergency admissions Too many admissions to nursing and residential

care Recognition by partners of the need to address

through a step by step change in service delivery Commitment to redesign urgent care Evidence that 5 day working creates

dysfunctional service pressures

Integration and Better Care Fund

7 day services

Community Rapid

Response Team

OD: Leadership programme

Prevention agenda and tele-health

Risk stratification

Single point of access

Dudley Care Home

programme

Integrated teams

Dudley was successful in applying to be one of the National Early Adopters

Cross health economy working group set up Working with NHS Improving Quality Team Three main areas of focus Mapping of services Developing community standards Sharing best practice with other early adopters

7 day services

Post weekend peaks in admissions Postponement of discharges due to absence

of support services – therapy, pharmacy etc.. Unnecessary admissions due to absence of

more appropriate primary and community health services

Inconsistency of patient experience and response, 7 days per week

7 Day Response To Avoid…..

Community Mental Health Teams: adults

and older people

Palliative care teamHeart failure-

joint pathway with acute

OT

Physio

Care home nurse

practitioners

Stroke

NeurologySocial

service teams

SLT

Current 7 day workingCurrent 7 day working

From July 2014From July 2014

Potential to move to 7 days in 2014

Potential to move to 7 days in 2014

MH Crisis Resolution

Community Rapid Response Team

Tele-care services

Dementia Gateways

District Nurses Current

7 day working

Intermediate Care

Community Respiratory Team

Virtual ward (Case Managers)

Evidence base:- 19,500+ over 65 arrived at ED 14,500 admissions over 65 10,000+ over 75 6,500 admitted for 2 days or less 85% arrived by ambulance

Community Rapid Response Team

Team of 9 Advanced Nurse Practitioners (ANP) Integrated with social care assistants and care

home nurse practitioners ANPs take a referral or co-respond with West

Midland Ambulance Services Assess, diagnose, initiate treatment, instigate

social care package if required and refer to integrated teams

Community Rapid Response Team

Community Rapid Response Team for Older People with Frailty

Integrated with Care Home Nurse Practitioners and Social Care Assistants

PATIENTS

WMAS

NHS 111

GP Out of Hours Community Nursing Teams

Assessment by ANP or Care Home Nurse PractitionerWithin one hour

Step down to Locality Integrated Teams

Single Point of Access forAdvanced Nurse

PractitionerBased at WMAS

Admit to

EAU

- Initiate treatment → - Initiate care package → up to 7 days (then review) - Initiate care plan

Practice integrated teams To consist of GP,

pharmacists, community nurses, named social and mental heath workers.

To review risk stratification tools and agree a Care Coordinator for complex cases

GP Leadership posts in each locality

Service Integration

Infrastructure for integration

A comprehensive organisation development programme

A common Information Technology platform A common approach to care planning An agreed performance framework

Over 2,200 residents in nursing and residential homes registered with a Dudley GP

High number of urgent care admissions Dudley Care Home GP programme operates to

provide proactive care and initiate advanced care plans.

Team of 6 care home nurse practitioners to double in size to be integrated with rapid response team and become a 7 day service.

Dudley Care Home Programme

Proposal is to have a Single Point of Access phone number for community health and social care services

To include a fourth option where there is more than one problem/issue and requires triage.

This will enable effective triage and the call handler takes on the role of a facilitator rather than navigator.

Single point of access

Develop self care programmes Develop technology including remote

monitoring tools (tele-health) Increase utilisation of voluntary sector

(community link workers) Social prescribing

Prevention agenda

Palliative and end of life care

Investment in palliative care services including a new palliative care consultant

Practice identifying more people in their last year of life to ensure a multi-disciplinary team approach and support

Increase and standardised approach to advanced care plans

More people at end of life having choice of preferred place of care

Patient perspectives addressed via the health economy Integrated Working Group

Aim is to capture the actions and improvement that need to be implemented.

Feedback given to the patient, carer or advocate that provided the story/experience.

Learning from patient experiences

Questions?

1. In your case study what elements of the service worked well?

2. What elements didn’t work well?3. What could have worked

differently?