11

Presentation

on

Primary Care Teams

from

Anne O’Connor, Local Health Manager, North Anne O’Connor, Local Health Manager, North West DublinWest Dublin

to

Regional Health Forum – Dublin North East

22nd March, 2010

22

Primary Care Team

Network Services

33

Primary Care Team VisionPrimary Care Team Vision

““Our vision is to develop and deliver a Our vision is to develop and deliver a

comprehensive, coordinated and continuous comprehensive, coordinated and continuous

Primary Health Care Service accessible to all”Primary Health Care Service accessible to all”

44

Key MessagesKey Messages

31 Primary Care Teams in place in DNE as of Jan 2010 and an 31 Primary Care Teams in place in DNE as of Jan 2010 and an additional 54 teams in place at end of 2010 (85 teams).additional 54 teams in place at end of 2010 (85 teams).

Teams providing more care locally.Teams providing more care locally.

Range of services including falls prevention and Warfarin checks.Range of services including falls prevention and Warfarin checks.

Shift in resources from hospital to community.Shift in resources from hospital to community.

Single services directorates linking with Clinical Directorates.Single services directorates linking with Clinical Directorates.

Progressing with key performance measures and outputs for PCTsProgressing with key performance measures and outputs for PCTs

55

LHOLHO Staff Staff reconfigured reconfigured at Dec. 2009at Dec. 2009

PCTs in PCTs in place – Jan place – Jan 20102010

PCTs in PCTs in place – Dec place – Dec 20102010

PCTs in PCTs in development development – Dec 2010– Dec 2010

Cavan/Cavan/

MonaghanMonaghan

(14)(14)

101.6101.6 55 + 4 = 9+ 4 = 9 55

Meath (18)Meath (18) 57.857.8 33 + 4 = 7+ 4 = 7 22

Louth (12)Louth (12) 65.665.6 NilNil 88 44

Dublin NorthDublin North

(27)(27)

236.57236.57 88 + 19 = 27+ 19 = 27 NilNil

Dublin North Dublin North West (24)West (24)

104.07104.07 66 + 7 = 13+ 7 = 13 1111

Dublin North Dublin North Central (21)Central (21)

99.799.7 99 + 12 = 21+ 12 = 21 NilNil

66

SummarySummary

Total no. of Total no. of PCTs – DNE:PCTs – DNE:

Total no. of Total no. of PCTs in PCTs in place at Jan place at Jan 2010:2010:

Overall % Overall % achieved at achieved at Jan 2010:Jan 2010:

% of staff % of staff reconfigured reconfigured from no. from no. identified:identified:

116116

--

3131

(85 by Dec (85 by Dec 2010)2010)

26.7%26.7%

(73%)(73%)

100%100%

--

77

What are the Benefits to the Client ?What are the Benefits to the Client ?

Greater / easier access to servicesGreater / easier access to services

Key worker for clients with complex needs e.g. disabilitiesKey worker for clients with complex needs e.g. disabilities

Services planned and delivered in a structured manner Services planned and delivered in a structured manner

Patient has an advocate and single point of contactPatient has an advocate and single point of contact

Hospital Avoidance/Early DischargeHospital Avoidance/Early Discharge

Clinical Directors have point of contact and structure for integrationClinical Directors have point of contact and structure for integration

88

Services Provided in Primary Care Services Provided in Primary Care TeamsTeams

The transformation from unidisciplinary community based services The transformation from unidisciplinary community based services into PCTs has generated innovation:into PCTs has generated innovation:

Chronic Disease ManagementChronic Disease Management

Management of Continuing Care CasesManagement of Continuing Care Cases

Mental Health ServicesMental Health Services

Hospital integrationHospital integration

Health PromotionHealth Promotion

99

DNE - PCT InitiativesDNE - PCT Initiatives

Community Participation in Primary CareCommunity Participation in Primary CareDoppler training skills for nursesDoppler training skills for nursesSocial work participation in PCTsSocial work participation in PCTsParkinson’s Disease – Physiotherapy led groupParkinson’s Disease – Physiotherapy led groupProvision of Integrated Health and Social Care for Provision of Integrated Health and Social Care for Patient with Complex NeedPatient with Complex NeedAnte-natal and social care programmeAnte-natal and social care programmeExercise and Health Promotion for new mothersExercise and Health Promotion for new mothersFalls and Fracture Prevention Pathway Falls and Fracture Prevention Pathway

1010

What Services are the PCTs What Services are the PCTs Providing – Nationally?Providing – Nationally?

Diabetic ClinicDiabetic Clinic Heart HealthHeart Health Muscular / skeletalMuscular / skeletal

Minor Minor Injury/SurgeryInjury/Surgery

Mental HealthMental Health Dressing /Leg Dressing /Leg UlcersUlcers

Falls PreventionFalls Prevention ParentingParenting Mens Health Mens Health

Elderly Elderly Mobility/Healthy Mobility/Healthy AgingAging

Lifestyle, Activity & Lifestyle, Activity & NutritionNutrition

Women’s HealthWomen’s Health

Dietetic ServicesDietetic Services Ante Natal Ante Natal ClassesClasses

Integrated Cancer Integrated Cancer ServicesServices

1111

Other Services Provided by PCTsOther Services Provided by PCTs

Community Community Intervention Teams Intervention Teams

Rapid Access Clinic Rapid Access Clinic Home Care Packages Home Care Packages

24 hr Blood Pressure 24 hr Blood Pressure MonitoringMonitoring

Warfarin ClinicsWarfarin Clinics Access to X-Rays in Access to X-Rays in community community

Palliative Care Palliative Care Traveller Health Traveller Health Anxiety Management Anxiety Management

Asthma Asthma Group/SpirometryGroup/Spirometry

Hydro PhysiotherapyHydro Physiotherapy Stroke RehabStroke Rehab

Arthritis ClinicArthritis Clinic Child Health Child Health Parent Training Parent Training Course Course

Sexual HealthSexual Health Pulmonary Rehab Pulmonary Rehab Breastfeeding Group Breastfeeding Group

Podiatry Clinic Podiatry Clinic IV therapyIV therapy

1212

Integrated Working with AcuteIntegrated Working with Acute

Pre AdmissionPre AdmissionPoint of Contact with Acute Hospital ServicePoint of Contact with Acute Hospital ServicePost AdmissionPost Admission

Chronic illness Framework Chronic illness Framework – Shift from episodic acute hospital care to integrated care focused on Shift from episodic acute hospital care to integrated care focused on

primary care.primary care.

Integrated Clinical Care PathwaysIntegrated Clinical Care Pathways– Discharge planningDischarge planning– Shared care – diabetes, asthmaShared care – diabetes, asthma– Current hospital care to be provided in the community e.g. cancer Current hospital care to be provided in the community e.g. cancer

initiative, minor surgeryinitiative, minor surgery– Access to Diagnostics Access to Diagnostics – OPD direct access to hospitalOPD direct access to hospital

1313

Mental HealthMental Health

Underlying most Underlying most presentations in Primary presentations in Primary CareCareTeam approach provides Team approach provides ideal opportunity to ideal opportunity to address thisaddress thisLiaison modelLiaison model– 60% teams direct links or 60% teams direct links or

MH person on teamMH person on team– Helps overcome stigmaHelps overcome stigma– Stepped care – Stepped care –

bibliography, discussion, bibliography, discussion, referralreferral

1414

Falls PreventionFalls Prevention

34,000 admissions per year 34,000 admissions per year due to fallsdue to falls

Hip fractures – €35m per yearHip fractures – €35m per year

2 out of 3 over 65 who fracture 2 out of 3 over 65 who fracture hip never return homehip never return home

Falls Prevention Falls Prevention – Ideally suited to PCTIdeally suited to PCT

– 25 PCT’s delivering Fall 25 PCT’s delivering Fall ProgrammesProgrammes

– Programmes reduce falls by 15 Programmes reduce falls by 15 – 30 % – 30 %

1515

WarfarinWarfarin

1.6% population = 67,200 1.6% population = 67,200 personspersons

6 – 8 visits per year6 – 8 visits per year

Point of care test + decision Point of care test + decision support softwaresupport software– Results in 5 minutesResults in 5 minutes

Patient satisfactionPatient satisfaction

Need to transfer resources to Need to transfer resources to PCTPCT

1616

InfrastructureInfrastructure

Six primary care facilities will come on stream in DNE in 2010:Six primary care facilities will come on stream in DNE in 2010:

Airside, SwordsAirside, Swords

CavanCavan

KellsKells

Blanchardstown/MulhuddartBlanchardstown/Mulhuddart

Blanchardstown/Mulhuddart/TyrrelstownBlanchardstown/Mulhuddart/Tyrrelstown

TrimTrim

1717

In ProgressIn Progress

Staff Reconfiguration – 665 staff reconfigured to PCTsStaff Reconfiguration – 665 staff reconfigured to PCTs

Development Posts – 72.66 posts filled to date.Development Posts – 72.66 posts filled to date.

Standardised Service Delivery through PCTsStandardised Service Delivery through PCTs

Governance ArrangementsGovernance Arrangements

Performance Indicators – Chronic Disease Management:Performance Indicators – Chronic Disease Management:- Diabetes- Diabetes- Asthma- Asthma

Engagement with GPsEngagement with GPs

1818

Key Dependencies for Achieving Key Dependencies for Achieving Targets in 2010Targets in 2010

Cessation of industrial actionCessation of industrial action

ICTICT

Administration supportAdministration support

Agreement on appropriate governance structuresAgreement on appropriate governance structures

Successful GP engagementSuccessful GP engagement