Commissioning Patient Centered Care & Improving Outcomes for People with Cancer
Commissioning for Outcomes 7-day services across the community
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Transcript of Commissioning for Outcomes 7-day services across the community
Commissioning for Outcomes7-day services across the community
Paul MaubachChief Accountable Officer
Dudley CCG
Dudley CCG: context
CCG registered population = 312,000 48 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.
Our starting point
Population-based healthcare
Our CCG is a population-based organisation of c.310,000 registered members
A substantial proportion of the national outcome measures are population based:
• NHS Outcomes Framework• Adult Social Care Outcomes Framework• Public Health Outcomes Framework• CCG Outcomes Indicator Set
Deaths by Day in Dudley - 2012
Day Mortality (Ave deaths per day)
Sunday 7.5
Monday 7.8
Tuesday 7.6
Wednesday 7.6
Thursday 8.1
Friday 8.4
Saturday 7.8
Local Dudley Service Provider
Need not Convenience
‘Our caring, compassionate and highly experienced staff are available 24 hours a
day where you can be guaranteed of a personal service from the first call. If you
can't get to us don't worry, we will be happy to visit you in the comfort of your
own home’
A Mutualist Approach
Shared Ownership Each citizen is a registered member
Shared Responsibility Co-production with the individual Services working together
Shared Benefits Personalised and population outcomes
7 day services: variation in delivery
Mon Tue Wed Thu Fri Sat Sun
-15
-10
-5
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Average Net flow of Patients (admissions vs discharges)
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…..
Mapping services – moving some to 7 days Introducing new services – rapid response Improving infrastructure – standard, mobile IT Developing community standards System alignment - to share responsibility Organisational Development – whole system New innovation – patient-led outcomes Commissioning for outcomes
7 day services – Early adopter
7 day services – connection to Integration & 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
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 working
From July 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)
Care home provision
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
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
Over 2,200 residents in nursing and residential homes registered with a Dudley GP
High number of urgent care admissions Dudley Care Home LES 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
Imperative that community practitioners have access to pertinent information and particularly for a 7 day service when practices are closed.
All practices now on EMIS web Piloting tablet using ‘Inchware’ technology to
access medical information remotely including the ANPs
Improving Infrastructure: Mobile IT
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ACG Probability of Future High Cost
Actual Avg no FHS
Actual Avg no OPAs
Actual Avg no AE Attendences
Identification of risk using ACG tool MDT Care Planning Care gap
Improving Infrastructure: Risk Stratification
1. Patient experience2. Integrated team review3. Information and communication4. Diagnostics 5. Speed of access and assessment in the community6. Mental Health7. Quality Improvement8. Palliative and End of Life
Community Standards
Community nursing and therapy services have a single point of access
Social services have a single point of access Both in the same building! Moving to joining together and include mental
health
Aligning Services: Single point of access
Practice integrated teams GP, pharmacists, community nurses,
named social and mental heath workers. To review risk stratification tools; agree a Care Coordinator for complex cases; take shared responsibility for outcomes
Locality MDT teams GP Leadership posts in each locality.
Remit of reviewing collective outcomes of all teams in their locality and ensuring pathways to locality to borough wide services function effectively
Aligning Services: Integration Model
Dudley Leadership Group (System resilience group) Vertical authorisation for the work
Change Project Team Early adopters for our Analytical Network Change Process Recognises importance of shared responsibility and networked leadership
Information Sharing and Development Days: New Working Practices to Improve delivery All front-line staff go through the same induction and development programme
Facilitated Multi-Professional Team Working: To deliver networked care for their population Planning how to work together, rather than have imposed top-down solutions
OD programme
Person
GP Practice
Community
CCG / specialist (hospital ?)
teams
Registered Member
Based in a Locality
Part of a System
Aligned, Networked Population Health and Wellbeing Services
Commissioning for outcomes
From a Representative approach: Patient perspectives and involvement is standard
To: Fully Participative approach: Development of systematic tool (PSIAMS) to record the patient
experience of care Enables patient to establish their own outcome goals with the services
and chart their progress against them Includes health and wellbeing as well as social impact outcomes Piloting with VCSE organisations
being upskilled & changing their practices. Enables market entry for smaller organisations
Gives us outcome data for every person receiving care
Patient-led outcomes
Population outcomes
With networked teams operating on the same population basis we can now implement performance management and incentives for population-based outcomes
Practice networks link collectively to the system network Developing shared outcomes across providers Both vertically and horizontally
Introducing first set of incentives for 15/16 contracts Join our working group!
A Mutualist Approach
Shared Ownership Each citizen is a registered member
Shared Responsibility Co-production with the individual Services working together
Shared Benefits Personalised and population outcomes