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KNOWSLEY CARE CAMPUSWORKFORCE REDESIGN ENGAGEMENT METHODOLOGY
Presented by: Julie HollandDate: September 2011
Methodology
• Organisation Development Services Population Centric Model for Workforce Planning (ODS 2008).
• Skills for Health - Competency Based Planning tools. (SfH 2011)
JH/MAY11
Patient Proxy - Fred & Sonia• elderly couple (80+) • live in rented accommodation
(private tenants) with access difficulties, and poor facilities/amenities and poor transport networks.
• have five children 3 very supportive 2 estranged. 1 estranged son is the landlord of their home and rent arrangements are difficult.
• Family dynamics are strained resulting in feuds’, and some complex financial issues.
• both socially isolated and lonely and have 5 pets to manage.
• benefit dependent.• Sonia has diabetes, angina and
epilepsy
• totally dependent on family for her care following a stroke, and is housebound.
• communication difficulties (speech) and depressed although mentally bright.
• Sonia is approaching the end of life and has chronic pain and pressure sores.
• She is a smoker and occasional drinker.
• Fred is Sonia’s main carer• has rapidly declining health due to
neglect. • history of COPD, prostate cancer,
hypertension and arthritis.• struggles to care for Sonia and is
often short tempered, stressed and verbally aggressive and is restricted by his wife’s immobility.
• Fred is an ex-smoker.
4 JH/MAY11
SONIA’S NEEDS
BE PAIN FREE
MONEY WORRIES
WOUND TO HEAL TO TALK & BE LISTENED TO
FEEL SAFE
BE ABLE TO GO OUT
HELP HERSELF
WORRIED ABOUT DYING
5 JH/MAY11
FRED’S NEEDS
HELP WITH SONIA
MONEY WORRIES
TO BE PAIN FREE & ABLE TO BREATHE
TO TALK & BE LISTENED TO
FEEL SAFE
BE ABLE TO GO OUTHELP WITH DOMESTIC WORK
WORRIED ABOUT SONIA DYING
6 JH/MAY11
SONIA’S NEEDS
BE PAIN FREE
HFM A2.4 HFM B1.1 HFM B14.2HFM A2.5 HFM B3.1 HFM B15.1HFM A2.8 HFM B4.3 HFM B15.6HFM A2.9
MONEY WORRIES
HFM 1.5HFM B16.4HFM C2.4HFM C2.6
WOUND TO HEAL
HFM A2.4 HFM B1.1 HFM B4.3 HFM A2.5 HFM B3.1HFM A2.8 HFM A2.9 HFM B14.2
TO TALK & BE LISTENED TO
HFM 1.2 HFM C2.6HFM 1.4 HFM 6.1
FEEL SAFE
HFM 3.5HFM B16.4HFM C2.4HFM C2.6
BE ABLE TO GO OUT
HFM 3.5 HFM A2.9HFM 3.8 HFM B3.1HFM 6.1 HFM B16.4 HFM C2.4
HELP HERSELF
HFM 1.5 HFM B16.4 HFM C2.4HFM B3.1 HFM C2.1 HFM F4.4HFM B15.8 HFM C2.2
WORRIED ABOUT DYING
HFM 1.5 HFM B18.1HFM B3.1 HFM C2.6HFM B14.2
7 JH/MAY11
FRED’S NEEDS
HELP WITH SONIAHFM 3.8 HFM 6.1 HFM B17HFM B2.2 HFM C2.6 HFM F4.1HFM B4.3 HFM C2.4
MONEY WORRIES
HFM 1.5HFM B16.4HFM C2.4HFM C2.6
TO BE PAIN FREE & ABLE TO BREATHE
HFM A2.4 HFM B1.1 HFM B14.2HFM A2.5 HFM B3.1 HFM B15.1HFM A2.8 HFM B4.3 HFM B15.6HFM A2.9 HFM B15.8
TO TALK & BE LISTENED TO
HFM 1.2 HFM C2.6HFM 1.4 HFM 6.1
FEEL SAFE
HFM 3.5HFM B16.4HFM C2.4HFM C2.6
BE ABLE TO GO OUT
HFM 3.5 HFM A2.9HFM 3.8 HFM B3.1HFM 6.1 HFM B14.2
HELP WITH DOMESTIC WORK
HFM 3.8 HFM B16.4 HFM C2.6HFM 6.1 HFM B17 HFM C2.4HFM A2.4
WORRIED ABOUT SONIA DYING
HFM 1.5 HFM B18.1HFM B3.1 HFM C2.6HFM B4.3 HFM B14.2HFM B18.3
8 JH/MAY11
Fred & Sonia’s Needs Competences
JH/MAY11
PATIENT PROXY HFM SfH REFERENCE FUNCTION SfH COMPETENCE
SONIA & FRED’S NEEDTo talk and be listened to.
CORE 1 COMMUNICATION HFM 1.2 Communicate effectively
CM G4 - Communicate with individuals, groups and communities about promoting their health and wellbeing in adefined caseload
HFM 1.2 Communicate effectively
CHS48 - Communicate significant news to individuals
HFM 1.2 Communicate effectively
GEN62 - Collate and communicate health information to individuals
HFM 1.2 Communicate effectively
GEN97 - Communicate effectively in a healthcare environment
HFM 1.4 Develop relationships with individuals
HSC233 - Relate to and interact with individuals
HFM 1.4 Develop relationships with individuals
CHS100 - Develop relationships with individuals with long term conditions
CORE 6 EQUALITY & DIVERSITY
HFM 6.1 Ensure your own actions support equality of opportunity and diversity
HSC234 - Ensure your own actions support the equality, diversity, rights and responsibilities of individuals
SPECIFIC C HEALTH PROMOTION
C2.6 Act on behalf of an individual, family of community
HSC368 - Present individuals' needs and preferences
C2.6 Act on behalf of an individual, family of community
HSC410 - Advocate with, and on behalf of, individuals, families, carers, groups and communities
Knowsley Care Campus
Data Collection & Analysis; diagnostics
Single Point of AccessReferrer
Entry: Critical Episode Risk Stratification New patient
Step Down From Active
Case Management
Joint Multi Disciplinary
Meeting
Eligible for Active Case Management Allocate to Key worker
Active CaseManagement
Signpost to Other Services; other pathways
P
Discharged
Deceased
GP
Specialist
Practitioners/Nurses
Intermediate
Patient
Care
Third
Sector
Reablement
Family
Carers
Patient Centred Care
Care Co-Ordination
Key Worker; Active Monitoring
Effective Utilisation of Integrated Resources
Promotion of Self Care/
Management
Direct
Care
Step Down
•Transfer to other care pathways
•Self Caring
•No longer risk stratified (return to general practice for routine management
Pathway for Critical Episode
Clinical Triage
STEP 1.
STEP 2. STEP 3.
STEP 4.
STEP 6. STEP 7.
STEP 8.
STEP
5.
STEP 9.
CORE WORKFORCE:
•Assistant Practitioner
•Community Matron
•Community Staff Nurse
•District Nurse
•Health & Social Care Worker
•Re-ablement Worker
•Social Worker10 JH/MAY11
Fred & Sonia’s Care Campus PathwaySTEP 1. Fred phones the single point of access requesting an urgent response to Sonia ‘s deteriorating health.
STEP 2. Urgent referral process set in motion - practitioner contact within 4 hours.
STEP 3. Practitioner reviews Sonia’s existing electronic health records in the community.
Urgent response- practitioner visits within 4 hours to assess and address Sonia’s urgent needs.
STEP 4. Practitioner presents Sonia & Fred’s current health status and needs to MDT meeting – Case Management agreed . STEP 6. Key worker allocated
STEP 7. Active Case Management. Assessment of Sonia & Fred’s needs, intervention, advice, information and review of health & wellbeing.
STEP 8. Step down from active Case Management. Sonia & Fred remain on the District Nurse caseload to address Sonia’s pressure area needs.
11 JH/MAY11
Fred & Sonia’s Care Campus CompetencesPatient’s Perspective/Need
Service Provider
Role/responsibility
Health Functional Map
SfH Reference Function SfH Competence
STEP 1.
Sonia’s health is deteriorating.
She is experiencing increasing pain.
She is unable to sleep.
She is placing increasing demands upon Fred that he cannot address.
Fred is worried about Sonia and wants help for her.
Fred’s health is also deteriorating as he attempts to take care of Sonia.
Fred phones the Care Campus phone line to request an urgent response.
Fred wants to know how long it will take for someone to visit?
STEP 1.
Single point of access (SPOA)
Call received by Admin staff.
Consent sought.
Fred listened to and details documented.
Specific questions asked from script.
Fred reassured and informed that a health practitioner will be with him within 4 hours.
Admin staff confirms that they will phone Fred back to inform him who the health practitioner will be.
Any immediate relevant advice given.
CORE1
COMMUNICATION
SPECIFIC B
HEALTH
INTERVENTIONS
CORE 6
EQUALITY &
DIVERSITY
CORE 1
COMMUNICATION
HFM 1.2
Communicate
effectively
HFM 1.4 Develop
relationships with
individuals
HFM B1.1 Obtain
valid consent for
interventions or
investigations
HFM 6.1 Ensure
your own actions
support equality of
opportunity and
diversity
HFM 1.5
Provide information,
help and guidance
HFM 1.2
Communicate
effectively
GEN97 – Communicate
effectively in a healthcare
environment
GEN21 – Interact with
individuals using
telecommunications
HSC233 - Relate to and
interact with individuals
CHS100 – Develop
relationships with
individuals with long term
conditions
CHS167 - Obtain valid
consent or authorization
HSC234 - Ensure your
own actions support the
equality, diversity, rights
and responsibilities of
individuals
HSC26 - Support
individuals to access and
use information
HSC21 – Communicate
with and complete
records for individuals
C A
R E
C
A M
P U
S
CASE MANAGEMENT
CASE MANAGEMENT
EPISODE OF CARE/INTERVENTION
LONGTERM CONDITIONS POPULATION – SELF & GENERAL PRACTICE MANAGEMENT
Step Up/ Step Down
Trigger points for patients to access appropriate service and support based
on risk factors
RISK STRATIFICATION = HIGH
RISK STRATIFICATION = V. HIGH
Core workforce competences:100HFM 1.2 HFM 4.6 HFM A2.4 HFM B3HFM 1.4 HFM 4.7 HFM A2.5 HFM B14HFM 1.5 HFM 5.1 HFM A2.6 HFM B16HFM 2.1 HFM 5.2 HFM A2.8 HFM C2HFM 2.2 HFM 6.1 HFM A2.9 HFM D2HFM 3.5 HFM A2.1 HFM B1 HFM F4HFM 3.8 HFM A2.3 HFM B2
High level workforce competences: 17HFM A2.2 HFM B16.4HFM A2.3 HFM B17HFM A2.4 HFM B18.1HFM B14.2 HFM B18.3HFM B15.6 HFM C2.5HFM B15.8
Very High level workforce competences: 4Skills for HealthHFM B4.2HFM B4.3HFM B14.1HFM B15.1
KNOWSLEY CARE CAMPUS WORKFORCE
COMPETENCES
CORE WORKFORCE: Assistant practitioner. Community Matron. Community Staff Nurse. District Nurse. Health & Social Care Worker. Re-ablement Worker. Social Worker.
13 JH/MAY11