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‘The right healthcare, for you, with you, near you’
NEW MODELS OF CARE
IN WILTSHIRE
‘The right healthcare, for you, with you, near you’
CCG Strategy
Local Implementation
‘The right healthcare, for you, with you, near you’
Wiltshire Context
Demographic Drivers – ageing population
Activity levels – growing demand for healthcare
Financial Challenge
Wiltshire Joint Strategic Assessment 2012/2013 ‘A Single Version of the Truth’, Wiltshire & Swindon Intelligence Network
‘The right healthcare, for you, with you, near you’
Future Care Model
Enhanced use of technology including remote monitoring / response
Integrated CYP services [HV. Nurse]
Hospices
A&E
Specialist Nurses
Medical Outpatients Primary Care Facility
MAU / ACE
Therapies
Outpatient Advice & Guidance
Non Consultant-led Outpatients
Medical & Surgical
Core & consistent GMS / PMS 08:00 to 18:30
Same day rapid access minor illness – 7day
Community Care Teams
Mental health primary care liaison
service
Mild to Moderate Mental Health Services
Diagnostics- Ultrasound and Bloods ? Plain film X-ray
Hospice at Home Core 7 day pharmacy
MDT Teams
Carers incl 3rd sector
Care Co-ordinators
Dementia Assessment & Management [simple cases]
Reablement
Patient Advocacy & Support
LIFT
Intermediate care co-ordination [STARR]
NHS 111 (mandatory)
Community Geriatrician
Medicines Mx
Intermediate Care
Help to Live at Home
Carer Support
Information and Advice
Voluntary Sector
Obstetrics
‘The right healthcare, for you, with you, near you’
System level implementation – solutions focused on non elective activity and pathways within the ED and
admitted care within and across providers
Locality based implementation – focusing on solutions for patients before they reach the hospital and after
discharge back into the community
Strategy to Implementation
5
Out of Hospital Care Emergency Dept. Admitted care/discharge.
‘The right healthcare, for you, with you, near you’
CCG Strategy
Financial Position
Local pressures
Local demographics
Local arrangements
Locality
Locality Strategy With regards the local position - what if tackled will have the greatest impact on delivering the
strategy and financial challenge?
Implementation Plan What are the key steps to achieving this?
Strategy to Implementation
‘The right healthcare, for you, with you, near you’
2015/16 Planning: Locality Packs
‘The right healthcare, for you, with you, near you’
Process of Developing Local Plans
To start developing locality based solutions for patients before they reach the hospital and after discharge back into the community This is the first stage of the process, to:
• Understand key trends • Confirm areas of focus • Agree the “deep dive” needed
After this session:
• Produce “deep dive” information • Review additional information • In second session develop root cause
analysis to understand real reason for the trends identified
‘The right healthcare, for you, with you, near you’
What’s in the locality packs
9
A&E attendances Emergency admissions
• Arrival source • Disposal • Arrival time • Frequent flyers
• Admission method • Primary diagnosis • Frequent flyers • ACS conditions • Arrival day
‘The right healthcare, for you, with you, near you’
Next Steps
‘The right healthcare, for you, with you, near you’
Locality Planning – population based, commissioning
priorities
‘What if tackled would have the greatest impact’
Locality Implementation – patient focussed, operational improvements, provider view
(e.g. Community Teams, TCOP, Federating, local 100 day
challenge issues)
‘Making it happen’
Planning and Implementation
‘The right healthcare, for you, with you, near you’
Locality Plan Example
Access to Specialist
Opinion – Advice and Guidance
and Virtual Clinics
Risk Stratification – Frequent Flyers
Care Homes
Prescribing
Service Gaps
IV , MH Crisis
Int. Care beds, CAMHS talking
services
TCOP – ECP
UPCC Development
Operational Issues
1. ICT alignment
2. Communication
3. D/C information
Fun
din
g A
lign
men
t
‘The right healthcare, for you, with you, near you’
Locality Implementation
CCG Strategy
Financial Position
ocal p ess es ocal e o aphics ocal a an e ents
ocality
e o els o a e ppo t nities to i p o e ca e o
patients ithin c ent syste esi n
Integrated Team(s)
100 day challenge
Transforming Care for Older
People
Wave 2 PMCF criteria assessment
PMCF Bid
Implementation Plan
Locality Plan
‘The right healthcare, for you, with you, near you’
West Wiltshire Locality Plans
Devizes
Bradford on Avon
Melksham
Westbury & Warminster
Trowbridge
tco e KPI’s Project milestones
‘The right healthcare, for you, with you, near you’
New models of community
healthcare in Bradford on Avon
Bradford on Avon & Melksham Health Partnership
‘The right healthcare, for you, with you, near you’
What’s happening in
Bradford on Avon?
Multi disciplinary meetings – twice a month
Joint initiatives with Integrated Teams:
Leg Club, Memory Café, Balance and Falls Class
Next steps, a joint list of patients to manage – vulnerable
people at risk of hospital admission
‘Single View of the Customer’
‘The right healthcare, for you, with you, near you’
Transforming Care for Older People
Senior Nurse for Older People – managing a team, to
include:
• Care Co-ordinator
• Dementia Care Co-ordinator
• Nurses supporting Nursing Homes
• Emergency Practitioners – for Home Visits
Data showing reduction in emergency admissions and
lower OBDs in >75s
‘The right healthcare, for you, with you, near you’
Dementia Initiatives
4 x Dementia Champions 100 Staff now Friends
Monthly One-Stop Clinics for Dementia Diagnosis and Review
Dementia Friendly GP Practice Accreditation
‘The right healthcare, for you, with you, near you’
Integration Practice Roles
Integrated Team Leader
Care Co-ordinator
Dementia Co-ordinator
Dementia Advisor (AS)
‘The right healthcare, for you, with you, near you’
Memory Café (Pub)
‘The right healthcare, for you, with you, near you’
Bradford on Avon Leg Club
‘The right healthcare, for you, with you, near you’
Leg Club Recognition
Sho t liste o ‘Inte ate App oaches to a e’ 2015
Winner – European Wound Association Scholarship 2015
‘The right healthcare, for you, with you, near you’
Any questions?
Victoria Stanley
Service Re-design Lead (Urgent & Primary Care)/
Trowbridge Locality Lead
NHS Wiltshire Clinical Commissioning Group
Amanda Brookes
Business Manager
Bradford on Avon and Melksham Partnership
(BOAMP)
