Building healthy communities

Future model workshop

Agenda

• Recap

• Agree Future delivery model

• Scope functional units- exercise

• Outcomes- Exercise

• Pathways prioritisation

Well Person

Minor Illness

Community EPCT

Urgent Care /111/ OOH

Emergency/ A&E

Outpatient Care / Acute

Transition Care

LTC Chronic Care

End of Life

Rehab/ Enablement/ CHC Case Management/ Care Navigators Care

Co-ordination Self Care / Prevention

• Cardiac rehabilitation • Community neuro rehab &

stroke service • CHC Wards – Fothergill Ward &

sally Sherman Ward • Cazaubon Ward • Pulmonary Rehab • SLT • PWLD • Free nursing care & Continuing

case management (FCN)

• Virtual Wards (VW) • Care Navigators • Telehealth • Supported Discharge • Hospital in-reach & Early discharge

• Rapid Response • SPA • District Nursing • New Entrants • Geriatrician – specialist

support • Clinical support to VW • Falls Service • Foot Health • continence

• Diabetic Service

CHS Services CHS Services CHS Services CHS Services

End of Life

• Palliative care including Cancer

• OT Palliative Care & OT community Hands

CHS Services

Community Care Home

CHS: Current Person/Patient Journey Pathway mapped to services

Virtual Ward/ Rapid Response

Frailty Unit

Complex Discharge

Rehab / 2˚Prevention

OP Community Service

Re-admission Avoidance

Enhanced Homecare

GP Services Acute Care Community Care/ Home

Care Plans / MDT Services

Ambulatory Care

LTC Chronic Care

Social care services

Current delivery model

Primary Care ELFT Other Contracts Social Care

• Extended Primary

Care Services

• GPs

• Some AQPs for

both Cardiology &

Diabetes

• Integrated Adult

community Health

Services

• Specialist Services

• Inpatients/outpatien

ts

• Day hospital

• Falls service

• Continuing care

/Case management.

• St Joseph’s

Hospice

• Homer ton NHS

Foundation Trust

(contracted activity)

• NELFT (contracted

activity)

• Patients First

• Ihealth

• Accelerate (tariff

based)

• InHealth

Delivery Team

• Enablement

• Care management

• Assessment

• Hospital discharge

Commissioning Team

• Homecare &

settlement

• Stroke prevention

• Dementia

ESTATES

Vicarage

Lane HC

Lord

Lister

HC

Shrewsbury

House HC

Stratford

Office

Village

West

Beckton

HC

East

Ham

Care

Centre

The

Centre

Manor

Park

Appleby

HC Romford

Rd HC

Clinical

ED

building

Sickle

Cell &

TC

5

Mohammed - Diabetes with Stroke (55 yrs old)

.

He has diabetes requiring insulin injections and regular checking of his blood

sugar levels. As a result of his diabetes he has kidney disease requiring dialysis

three times a week at Newham hospital. He sees his diabetes specialist in East

Ham but his GP surgery is near his home in Stratford.

He suffered a stroke two years ago and finds it difficult to move around the house - he

had physiotherapy in the past from the community stroke team and they came to his

home. They worked with the Occupational Therapists to install equipment including

grab rails and a raised toilet seat to help him manage at home.

He lives with his wife, who is his main carer, and children who find managing his health

conditions and appointments difficult. His wife isn't always sure who to ring first if

she needs help.

Camilla is Mohammed's Care Navigator - she is available in working hours during the

weekdays to help him and his family with things like booking transport to get to

appointments.

Mohammed has known his GP for many years and is happy having someone who

knows about him, his family, and his health problems. Sometimes though his GP has to

ask his wife what the other teams have agreed for his care as letters can take some

time to arrive in the post.

Current State

• Mutliple access

points

• Multiple locations

for out of hospital

care

• Dependant on

patient/ carer

competency

• Fragmented

experience

• Multiple records

• Delayed

discharge

• High

readmissions

• Minimal

prevention

MOHAMMED’S Future Pathway

Mohammed –

50 yrs old has

diabetes with

renal disease

Wife &

Carer

Homecare, Self -

Care, Prevention,

Well- being

advice diabetes

education, HHD

Telehealth, Skype Home monitoring Carer Support

Access

SPA

M

ult

i Age

ncy

Hu

b

He

alth

& S

oci

al C

are

DO

S SI

NG

LE A

SSES

SMEN

T

Hub

Diagnostics

Social Care

Voluntary service

Foot care/

Physio

Urgent Care Hub

Integrated workforce model – MDT Team, Case Management, CPN

Virtual Specialist Support (stroke/dialysis)

Facilities/ Services Provider

All Primary & Community Services

Single Shared Record- Integrated care plan

GP hub Neighbor

hood team

Newham BHC Vision

• Scope

Objectives Principles Outcomes Scope

1. SPA

2. MCP hubs- one

stop shop

around primary

care

3. Risk

stratification

4. Shared care

records

5. MDT teams,

integrated

workforce

model

6. Manage

Demand and

capacity

effectively

1. Community as

default

location of

care

2. Integrated

health and

social care

3. Family as a

whole

4. Choice and

empower

patient

5. Prevention

and promotion

6. Reduce health

inequalities

1. Get care right

first time close

to home

2. Reduction in

complication in

LTC

3. Reduction in

hospital visits

and stay

4. Early Return to

independent

living

5. Increased EOL

care at home

6. Improved

experience

1. All community

based

functions not in

scope of acute

or primary

contracts

2. Specialist

functions in

community to

support

pathways

3. Acute services

that can be

delivered in

community

4. Enablers

5. Out of scope

• Improving health outcomes through developing models of integrated care and focusing on prevention

• Reducing inequalities and improving accessibility • Reducing quality variation by ensuring equity of Health & Wellbeing outcome

CCG Objectives

Large acute based services

Multiple disconnected

Small community

services

Social care system- separate

CHS Transformation

Integrated Community

Hub

Nursing/

Residential homes

Enhanced primary

care

Voluntary service

Social Care

Multiple access points and

teams

MDT teams Care Close to home

Reduce hospital visits &stay

Improved outcomes & experience

Care locally accessible and responsive to patient needs provided in community or in people’s homes rather than hospital

Newham Community Services Proposed Programme Vision

IntegratedCommunity

Hub

Nursing/

Residen alhomes

Enhancedprimarycare

Voluntaryservice

SocialCare

MDTteamsHomebasedcare

Specialistsupport

SocialCare

Very

high risk

High risk

Medium risk

Low Risk

Proactive approach to support

behavioural change

Prevention and health promotion

Comprehensive risk stratification

Supported self care and monitoring

Personalised shared care plan

Care Navigation

Care Coordination

Case Management- step and step down

Reablement

Single Care Co-ordinator

Single Care Plan with EOL care

Rehab/ Respite care

Single Assessment Process

Single Point of Access

Shared Care Record

Risk Stratification/ Choice Integrated care close to home

Building Healthy Communities- Future Care Model

Well Person

Minor Illness

Primary care condition

Urgent Care /111/ OOH

Emergency/ A&E

Outpatient Care / Acute

Transition Care

End of Life

LTC Chronic Care

Risk Stratification/ Care Navigation

Single Point of Access

Single Joint Assessment framework

Building Healthy Communities- Future Care Model

Well Person

Minor Illness

Primary care condition

Urgent Care /111/ OOH

Emergency/ A&E

Outpatient Care / Acute

Transition Care

End of Life

LTC Chronic Care

Prevention and Well

being

Care close to home-

Low/Medium risk

Specialist services in community

Intermediate care

services- Pre-

hospital/ In-hospital care

Post-hospital care

Care close to home- High/

Very high risk

End of Life Care

Integrated Health and Social Care Functions

Core and Specific Pathways

Redesigned Estates and infrastructure

Integrate multidisciplinary team- new workforce model

Shared Care Record / Technology platforms

Scoping Process

• Identify priorities

and outcomes

• Analyse current

services and gaps

• Develop future

model- pathways,

services to deliver

• Define scope

• Detail specifications

Scope Principles

Define and procure the different functions that need to be provided to deliver

outcomes

Adult Community Functions that should be considered in scope for the re-

procurement are those that:

• Fall outside the definition of primary care and acute service provision

• Do not require a hospital infrastructure for delivery

• Can be linked/integrated with the provision of social care

• Are necessary to deliver the community elements of the CCG’s 5-Year Plan

• Functions that already being delivered or can be delivered in a community

or home setting

Case management Care navigation Supported discharge OT/PT Rapid response/VW Telehealth MDT Phlebotomy Wound care MH (CMI) Geriatrician services

Assessments Care management Enablement services Hospital discharge support Home care Home and settle service Stroke prevention services Dementia support services Neighbourhood teams

Remote

advice

Virtual

consults

Ambulatory

care

Consultant

clinics in

community

Stay-well partnership Marie-Curie Hospice care

IACH

Diagnostics

Screening

Consultations

Community procedures

End of Life care

Multimodality assessment and care plans

Specialist services

MH (SMI)

Rehab/ Reablement

Nursing/

Residential homes

Enhanced primary

care

Voluntary service

Social Care

Borough level services Equipment/ Appliances Wheelchair services SPA Continence services Teaching/training MSK

Integrated Functional Model

Scope of BHC linked to delivery of outcomes

Access: (Key outcome- Get it right first time!)

• Single point of access- (for what, how, when, from where?)

• ? 7 Day working or extended opening hours (for which

services?)

• One Stop Shop?- What services should be delivered at

Superhubs and locality GP hubs)

• Patient Access to records- is this a must? (What and How)

• Remote access to records by staff of all agencies- Shared care

record

• Comprehensive risk stratification (should this be used to direct

access?)

• Triage/ Single Mutli-agency Assessment framework

Prevention and promotion:( Key Outcome- Reduction in

Complications in LTC)

• Prevention and health promotion services ( What and how?)

• Prevention agenda interventions- are they in scope of BHC or

Public health program?

• Long term conditions early detection or screening (DM/

Obesity/ What else?)

• Comprehensive risk assessment and stratification

• Risks based personalized education/ wellness program (PHB)

• Mental health- (What should we offer at this stage)

Services to be procured

• SPA (RMS included)

• DOS????

• Shared care record/Interoperability

• Single Multi-agency assessment

• Risk Stratification

• Care plan (MDT)?????

• Prevention program-1- Diabetes

• Prevention program-2- Falls

• Prevention program-3- Obesity

• Prevention program-4- CVD

• Prevention program- 5- ????

• Health inclusion service

• EPCS ??? (what is it’s role- prevention

or treatment)

• Foot health

• Personal health budgets????

• Wellness program-1

• Wellness program-2

Scope of BHC linked to delivery of outcomes

Extended primary care team or IACH ( Coordinated care)-

(Key Outcome- Reduction in hospital visits and stay)

• Self care and health advisory

• Home monitoring

• Rapid response/ Community Nursing

• Care navigation

• Specialist services

Case Management/ Care Coordination- Flexible Step up

and step down care (Key outcome- Faster return to

Independent Living)

• MDT care planning

• Enablement

• Safe and faster Discharge (should it be with Acute???)

• Community beds

• Continuing Care/Case management

• Condition specific pathways (which ones? )

Services to be procured

• Virtual Ward (with clinical support)

• Hospital In-Reach & Early Supported

Discharge Service (Transition care)

• Rapid Response

• District Nursing Service

• Palliative Care – including Cancer

• Geriatrician – specialist support

• Care Navigators

• OT Palliative Care & OT

• Physiotherapy

• Telehealth

• Patient Appliances/Orthotics

• Diagnostics (AQP)

• Other AQP contracts- speciality services

• EPCS ??? (what is it’s role- prevention or

treatment)

• Wheelchair Services

• Rehab/ Enablement ????

• SLT

• Tissue viability

• Pathway specific services (LTC)

• LD services

• CPN

• Inpatient Community Care (ECC)

• Continuing Care/Case management- ???

• Day hospital???

Scope of BHC linked to delivery of outcomes

Improved End of Life care (Key outcome- Increase in

number of people dying at home/ preferred location)

• End of life care planning

• Step and step down care

• Access to respite beds

• Social services linked to EOL care

Improved overall experience for patients ( Key outcomes-

Improved experience scores)

• Experience monitoring

Other community services ( Are there any other services

that need to be procured to deliver core strategies?)

• Shifting outpatient care from acute to community

• Staff training/ new workforce model

• Services aligned to the TST, 5 year forward view etc

Services to be procured

• Adult Specialist Palliative Care (contract till

2019)

• Respite care

• HIV Neuro Rehab- (contract till 2019) • Community care homes ????

Do we need to specify and procure some

specific activities to ensure this?

• Patient experience monitoring- Audits

• Communications on services/ redesign etc

• Patient Education/ information

• Outpatient consultations in community(AQP

currently)

• Dermatology, Gynecology, Cardiology,

Rheumatology, Urology, Gastro, Renal

• Community procedures- Minor surgery

• Anticoagulation clinics

• Ambulatory care in community

Scope of BHC linked to delivery of outcomes

To be discussed for procurement scope based on envelope/ funding/ strategic fit:

Future services

Redesigned or renamed services

Acute services that can be delivered in community- OP, Ambulatory care, Minor

surgery and other procedures, diagnostics,

LBN services and their alignment

• Assessments

• Care management

• Enablement services

• Hospital discharge support

• Home care

• Home and settle service

• Stroke prevention services

• Dementia support services

• Neighbourhood teams

Out of Scope

• MSK

• Urgent care/111/OOH

• ???Services with contract

beyond Feb2018

Outcomes

• Increase Patient Empowerment and Self Care with focus on prevention and

health promotion

• An increase in the provision of care closer to home

• Reduce avoidable admissions and attendances to hospital

• An increase in integrated care (through case management, care planning

and risk stratification)

• Improved Patient Experience

• Improved end of life care at home

Additional slides

Key lessons learnt

Transformation ambitions can’t be achieved in short timelines, 5 to 7 years is better

than 3 to 5 years

Cost of transformation often underestimated or not fully detailed at time of

procurement

Providers have limited capability- match transformation ambition with provider

capabilities- Set realistic ambitions working with them

Data and base lining of current services is a key limiting factor in setting up outcome

based contracts. Be realistic with outcomes that can be realised in given timelines.

Shifting activities across care settings is not necessarily cost effective are the right

thing to do

Patient/ Public engagement and buy in to new models is critical if behavioural

change has to happen

Provider partnership models are often difficult and can be limiting factor in delivery

of integrated models

Programme success criteria

• Integrated working across organisations including primary care, voluntary sector and social care

• Integration in delivery across the different strategic CCG programs with community services element

• Deliver population based approach to care delivery and contracting

• Innovations in care provision and new provider models

NHS EXAMPLE

NHS EXAMPLE

Southern Health- Hampshire

Example

Model

The Newham JSNA in summary Two key processes

• Inequalities and vulnerable groups run across all domains of the JSNA

• Health protection processes to ensure that the population is protected from harm (immunisation, screening and communicable disease control)

Four key determinants driving need:

– Access to services and housing: Overcrowding 139,700

– Income: Income deprivation 80,200

– Living environment: Fuel poverty 46,200

– Crime: Number of crimes 25,085

Four priorities for health improvement and six priority disorders leading to poor life expectancy and healthy life expectancy

Mortality Healthy Life Improvement

CVD Mental illness and mental health Inactivity

Respiratory disease Musculoskeletal Smoking

Cancer Diabetes Obesity

Hypertension

– Most ethnically diverse borough in London - 72% of the population is BME – 27.8% of the population is under 20 (London 24.5% England 23.9%) – Over 65s population expected to grow by 37,000 (60%) over next 20 years – Patients with LTC account for 50% of GP appointments and 50% of inpatient bed days – 22065 diagnosed diabetics, growing at approximately 180 new cases per month – highest rate of age standardised diabetes in the UK

Patient and public feedback

ACCESS

- Use of Care Navigators

- One stop shop – with

services accessible in one

location

- Easy access to transportation

for appointments, etc.

- Easy access to up-to-date

records by professionals

and patients/carers alike

- Variation in opening hours, i.e.

evening and weekend

availability

- Awareness about the

different services available

- Interpreters available to allow

for foreign language needs

- Ability to self-refer

- Shorter waiting times for

appointments

COMMUNICATIONS

Communications was often cited as in

need of improvement, and covers:

- Communication to address

gaps between services and

acute/community care to help

ensure smooth transitions

- Professionals communicating

via social media

- Care Navigators, particularly

for patients with long-term

conditions

- Advocates to support patients

- Availability of face to face

appointments.

- Clear and simple information,

Including clear explanation

around diagnosis and

treatment.

- Printed information to take

away and read, especially on

specific conditions /

specialist services

QUALITY OF CARE

Patients prioritised quality, and

expressed a concern that workloads,

resource constraints and time pressure

were adversely affecting this:

- Better integration of health

and social care services

- Services to be culturally

appropriate

- Use of telehealth

- High quality and consistent level

of care wanted across all

locations and services – ideally

‘one stop shop’

- Expert, knowledgeable staff

- Compassionate staff

Feedback so far has indicated that the

quality of care received is often of a

high level, and that clinicians do their

jobs well. However, it is not always

consistent and clinicians do not

always have the time or knowledge

to deliver an optimum service.

PERSON-CENTRED

The expectation for health services to

be tailored to individual needs was

widely expressed:

- Patient-centred care, with

patients/carers having a say about

their care

- Need for a Care Navigator

- Advocacy support

- Use of telehealth

- A desire for more

preventative / health

promotion services

- Prioritisation when needs are

urgent, such as for

emergencies and for people

with long-term conditions

- Coordination and planning

that is comprehensive and

holistic

- Support groups for long-term

conditions such as cancer and

diabetes

Key drivers for change Transforming Services Together

• Sustainable hospitals

• Delivery of Care close to home

JSNA

• Focus on 40-65 year olds to prevent serious

ill health and problems

• Raise awareness on health promotion

• Implement a Prevention agenda.

Transforming Primary Care

• GP federations

• Clinical hubs/ Estates Strategy

National Planning guidance

• 7/7 working and improved access

• STP- location based care

• Health and social care integration- 2020

Five year Forward view

• New models of care

• Payment reforms (Capitation/ Prime /

Alliance contracts)

Why we need to change?

• Our population is projected to grow

considerably

• Our hospitals face unprecedented

demand for services and population

growth will require a further 550 beds

over the next 10 years. Extra funding

from the population increase will not

cover this cost or the care they require

• We need to change the social culture of

over-reliance on medical (and often

emergency) services.

• Our workforce is stretched. We are

struggling to recruit and retain the

number of staff we need.

• We need to improve the quality of care

and patient experience.

We need to redesign services to

keep people out of hospital in the

first place

TST

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