collaborative care for older citizens · 2019. 11. 19. · • getting to know each other exercise...

Collaborative Carefor Older Citizensin East Berkshire and South Buckinghamshire

Design Workshop 328th May 2015

Welcome and Introductions

• Housekeeping

• Rules of engagement

• Outline of agenda

• Getting to know each other exercise

• Photography, video and graphic artist

• Social media, twitter #newvisionofcare.

1

Rules of Engagement

• All fully present.

• All voices to be heard.

• Silence is consent.

• Respect all views.

• Permission to be radical and creative.

• We are where we are in the design process.

• Self-policing in groups.

• Please follow process.

2

Agenda

3

9.30am Welcome and introductions9.40am The Big Conversation9.50am Design so far. The outline high level model and components10.00am Designing the component parts of the model - Round 110.45am Break11.00am Designing the component parts of the model- Round 111.30pm Overview of the Care Act and its connections with CCOC11.45pm Designing the component parts of the model - Round 21pm Lunch1.45pm The emerging model2.15pm Interoperability to support the model3.30pm Break3.45pm Articulating the model4.50pm Story so far – in images4.55pm Next Steps5pm Close


The Big Conversation

Engaging patients and public so far

• Presentations at Older People Partnership Boards and Forum

• WAM

• Bracknell Forest

• Slough

• Two on-line surveys – Health Connect

• Public workshops 16 April and 14 May

• Twitter #newvisionofcare

6

On-line surveys

• First survey launched following first Design Workshop

• Three questions:

• To what extent you agree with the design principles

• If you could change one thing to improve services, what

would it be?

• What are the best bits we should keep and learn from?

• Survey closed on 28 April

• 29 responses received

7

Summary of results for first survey

8

• Broad support for principles

• Ideas for changing things for the better

• Better signposting and information

• Better transport

• Better integration of services

• Ideas for what are the best bits

• Volunteers and staff providing services

• Dealing with people as individuals

On-line surveys

• Second survey launched following second Design Workshop

• Five questions:

• To what extent do you support the following approaches to integrating

care?

• How effective do you feel the following methods would be for advertising to

older people?

• Which of the following suggestions for using technology would be

acceptable to you?

• Should we add an assessment for frailty in the health check offered to

those over 75?

• To what extent do you agree with the following suggestions for stimulating

discussion about end of life?

• Survey closed on 25 May

• 96 responses received9

Summary of results for second survey

10

Number of responses: 96

Question 1: Ideas for integrating care Really good idea / good idea

Single point of contact 96%

Smaller group of people providing care 87%

Single assessment for health and social

care

88%

Shared computer systems/information 90%

More involvement of voluntary sector 77%


11

Question 2: Best ways to reach older citizens - Top five suggestions

Leaflet delivered to home

TV screens in GP surgeries

Leaflets in GP surgeries and pharmacists

Village/parish newsletters

Websites


12

Question 3: Ideas for using technology more Would use

Making appointments using the internet 77%

Self testing kits at home 84%

Using your television to see and talk to person

providing care

54%

Using skype or other internet based

communications for face-to-face communication

55%

Question 4: Should we introduce an assessment for frailty?

Yes 94%

No 5%

Don’t know 1%


13

Question 5: Talking more about end of life Strongly Agree / Agree

Information available when making will 87%

Death Café 45%

Discuss with GP and recorded on patient record 84%

Information provided to new parents and

grandparents

50%

Part of discussion when diagnosing long term

condition

84%

Introduce discussion at school 47%

Introduce discussion as part of retirement

planning

83%

Public workshop 14 May

14

Single assessment

• One point of access, one assessment for health and social care needs

• Must be simple

Single point of access and signposting

• Integrated health and social care point of access• Must be 24/7 manned• Integrated record availability helps • Signposting to wider services• Dementia friendly town

Care and support planning

• Patient ownership of own health record• Sharing of health and social care information between

professionals• Technology to facilitate sharing of records; explain history

to doctors from a new specialist area – not every new medical practitioner

• Read notes before seeing patients • Plea for consistent personal carers


15

Effective Multi-disciplinary Teams

• Concern expressed that professionals becoming generic may be a problem as specialism could be lost. ‘Do not dilute skill by having one person do all’

• A pharmacist is most effective when he knows his patients and their carers; whether that pharmacy be in a GP practice or in the community.

• This is a good idea with teams of hospital and community staff working together across health and social care.

Care coordination

• A key improvement that needs to be made for older peopleas well as younger people with frailty.

• Named key workers keeping patient and family updated • Arrange and monitor service delivery • Needs back up / cover • Hand held records for patients

New out of hospital services –Locality hubs and virtual teams

• Specialist services for older people in GP practices • Need generalists – geriatricians and nurses • Facilities for step up/down beds • Where to base MDTs?• Coordination of discharge needs to be seamless and use

of the voluntary and social services.


16

Using assistive technology

• Recognition of huge potential and growing range of opportunities

• However, needs money to pay for wifi connections, training, support and help in appropriate languages

• Recognition of possible local training available including: U3A, schools IT teachers, prior government programmes

Other • Prevention and health education • Need to be careful not to exclude people that don’t have

easy access to internet – how can they be supported?


The Design so Far

Care and support model framework for Older CitizensStages How do we identify

people at need?

How do we

assess needs

and identify

goals?

What is available

to meet needs

and goals?

How to restore

and maintain

independence ?

What if crisis

occurs?

How do we

deliver End of

Life Care?

Places – where? 1 2 3 4 5 6

Home

(own home,

supported

housing, care

home)

Locality

(including day

centre, health

centre,

community

hospital etc.)

Hospital

(including acute

hospital

ambulatory care

and inpatient

settings)

18

Care and support model detailStages How do we

identify people at need?

How do we assess needs and identify goals?

What is availableto meet needs and goals?

How to restoreand maintainindependence ?

What if crisis occurs?

How do we deliver End of Life Care?

Places 1 2 3 4 5 6

Home(own home, supported housing, care home)

Systematic & consistent set of frailty tools used & shared across the whole system - self management to specialist. care.Marketing, and communications.Involve community.

Communication is key.Clear pathway & responsibilities – care coordination.Supported self management. Support VCS services.Unified care plan – needs clear accountability.Allow time for assessment. Assess carer & link careEngage people in care planning.Assertive outreach for difficult to engage people.

Person centred goals.Health promotion/public health campaigns –workplaces and media.Support self man.Care coordination (incl.EoL) & CP reviews.Integrated health & care support workers.Effective use of equip & technology.Befriending and bereavement support.MECC.Memory Clinic.Dementia sign-posting.

MDT reassess post big change in medical/social circumstances.Support self management. Prevention, early intervention & restoring independenceVirtual wardCGA by GP at home.Reablement.Smart technology.Virtual Ward.Befriending support.VCS incl. in pt recordIntegrated commissioning

MDT assess at home.24/7 social care.Virtual wards - rapid response.Support family & pets.CGA.Electronic patients records.Access to emergency care bedsReablementTele-consultation / skype.Access to emergency transport.

Honest conversations.-staff training.Public awareness.Gold Line.Early identification.Advance care planning part of frailty care planningSmart use of technology.Holistic approachRespect for cultures and traditionsLinks to Funeral Directors.Age UK guidance.Staff awareness and training.

Locality(including day centre, healthcentre, community hospital etc.)

Systematic & consistent set of frailty tools-as above.Tools are holistic.One number to call.Flags on IT systems.Pt ownership of info.Marketing, and communication.Targeting + resources.

Drop-in clinic- health promotionCare coordinator.Holistic assessments including needs and wants.Shared documentationClear pathway & care planSupportive self management.Use VCS.Single clinic appoint. for all health needs.Use resources and technology effectively

Person centred goals.Public health promotion.Coordinated care incl. transport requirements.Integrated health & care.Early diagnosis & intervention.MDT approach, incl. access to specialistsHub servicesRapid response, assessment and treatment.Use VCS servicesHubs, day centres, day hospital.

MDT assessment.Integrated rehabilitation in health & care services.Integrated transport.Shared patient record.Rapid access to community services.Befriending support.Self help and lunch clubs.Medicine review by community pharmacy.Use community hosp. toimprove independence.Real-time Monitoring.Ensure link to mental health.

Signpost community servicesIntegrated commissioning.24/7 rapid access, incl. community beds.System wide service directory.CGA.Team response to crisis management.Medication review.Mental health support –dementia and psycho-geriatrics.

Honest conversations.Hospice A&E and rapid response 24/7.Palliative care planning in Oncology.Clear EoL diagnosis.Constant review of plan & pt wishes.24/7 integrated working to provide seamless care.Smart use of technology.Bereavement counselling.Carer assess & care planning.Safeguarding.Develop CVS capacity.

Hospital(including acute hospitalambulatory care and inpatient settings)

Systematic & consistent set of frailty tools used & shared across the whole system - self management to specialist care.Flags on IT systems.

Communication is key.Shared patient information across whole system.Hospital coordinator.Engage hospital more & use tools to avoid admission.Patient held records.

Person centred goals.Public Health Education.Coordinated care PreventionAcute medical crisis management.Rapid response and assessment.Specialist support.

Independence focus in hospital.Stabilise then discharge to assess.Link patients to VCS during discharge.Electronic patient record.

Independence focus in hospital.In reach from community.Rapid integrated response team.CGA.Frailty unit in A&E.Admission, stay and discharge processes.

Honest conversationsHospice out reach support & advice

The outputs of workshop 2

were analysed and

summarised into this

framework

Draft component parts of the model.

1. Needs anticipation and identification2. Single Point of Access and signposting to care and

support.3. A single Care and Support Planning process.4. Multi-disciplinary teams (MDTs).5. Care coordination as a specific role in the MDT. 6. Enhanced (Integrated) services for Localities.7. Specialist and Hospital processes (Acute).8. Specialist and Hospital processes (Mental Health).9. Primary Prevention.

20

9 Draft transformational

components were highlighted

from the summary for further

definition

Stages How do we identify people at need?

How do we assess needs and identify goals?

What is availableto meet needs and goals?

How to restoreand maintainindependence ?

What if crisis occurs?

How do we deliver End of Life Care?

Places 1 2 3 4 5 6

Home(own home, supported housing, care home)

Locality(including day centre, healthcentre, community hospital etc.)

Hospital(including acute hospitalambulatory care and inpatient settings)

Care and support model graphic

(vi) Enhanced (Integrated) services for

Localities.

(i) Needs

anticipation

and

identificatio

n

(iii A

single

Care

and

Support

Planning

process.

(iv)

Multi-

disciplin

ary

teams

(MDTs).

(v) Care coordination as a specific role in the MDT.

(vii) Specialist and Hospital processes (Acute).

(ix) Primary Prevention.

(ii) Single Point of Access and signposting to care and support.

(viii) Specialist and Hospital processes (Mental Health).


Designing the component parts of the model - Round 1

Designing the component parts of the model -Round 1• Select which component you want to work on.

• Ensure all tables have the necessary people.

• Use your knowledge, research, experiences and design principles to answer the

questions on flipchart paper.

• Please clearly name the component on each page and the question numbers.

• Include the recorder’s email address.1. What is the key transformation the system component is being designed to

achieve?

2. How should the system component operate?

3. What skills and or roles must be involved to make it work as designed?4. How can you maximise the role of the voluntary sector and local community?

5. Which system components should be available 24/7?

6. Which system components should be co-located?

7. How can Technology or Assistive Technology support both the process and

person’s outcomes in this component?

8. Are there transport implications in the model?

9. Do you have any other observations for the design of this system component?

• Prepare and set up for Gallery Walk23

Break

24

Designing the component parts of the model -Round 1

Gallery walk to review the component parts of the

model. • One person to remain at your station to explain the

component to visitors and add any updates.

• The rest of the table will move clockwise to the next station.

(5mins per station)

• Station visitors to challenge and improve component design –being mindful of design principles, research and experiences

to highlight any gaps / opportunities

• Once all components reviewed return to original groups and

debrief.

• Capture changes and amendments and finalise your design.

• Collate all model components together on one wall25

1. Needs anticipation and

identification1. Key transformation – Help people live healthier + happier for longer

2. Operate– Earlier is better

– Person-centred / choice /personalised

– Accessible (e.g. considering skills + capacity)

– Ambitious + realistic

– Dynamic – repeated occasionally

3. Skills and Roles – Standardised assessment tool that can follow the person when assessing different services. Also Tech skills – data query for identification

4. Voluntary and community – Services have access to assessment and able to complete parts / elements of assessment ( + pharmacists)

5. 24/7 – Access to assessment available to all services when the person may access out of hours

2. Single Point of Access and

signposting to care and support1. Key transformation

– 1 Number sorts out everything, makes simpler for patients & staff

– Post It - Can 1 number sort out everything or put people in touch with right service? - Yes

– Single point – multi modality underpinned by strong local directory

– Right Skills / knowledge to diagnose / meet need

– Assess for support

– Post It - Berkshire wide - Berkshire Forest Council host Out Of Hours Social service for Adults and children. This could be enhanced to cover daytime hours – Ok!

2. Operate– For an identified cohort

– And generic

– And staff

– Main role is signposting and information• ? Do all queries come here? When it just become a layer?

3. Skills and Roles– New roles / needs training

– Problem solving capabilities

– Understanding of need and how to pull down from our local menu

– Training / Information Governance – data sharing

2. Single Point of Access and

signposting to care and support4. Voluntary and community

– Menu options

– Capacity building/Upskilling

– Post It – Who is goi g to a the u er – Care co-ordination team• Is 't that the NH“ Dire t’s Jo ? - No

5. 24/7– Web access

– 8am – 8pm for signposting

– Crisis response e.g. divert to Out Of Hours?

– Post It - Is a single point of access about a care co-ordinator for each individual rather than one place to get info? Answer – Part of a wider care co-ordinator team

6. Colocation– Depends

– Out Of Hours in day?

– Depends feed backdoor

– Post It -Single Point of Access Should not be age specific - Agreed

7. Technology– Directory Of Service – The menu

– 24/7 Phone direct / Website /etc.

3. A single Care and Support

Planning process• Takes time – Time that needs to be formal, Agencies/Parties buy into principles

• Resource issue

• Overcome fragmentation between practitioners and organisations starting with Health / Community / Social Care / Voluntary

• Post It - Early assessment + diagnosis + skilled workforce across disciplines

• Citize is at the e tre of pro ess… eeds to ork for differe t eeds / prese tatio s a d apa it• Post It - Who is going to be doing all of this / Capacity issue staffing?

• Holistic / person centred – The persons goals + outcomes they want to achieve

• Plan covers stronger (Post It - Very important) aspiration, maintenance, prevention, what to do if deterioratio a d risis, o ti ge (Post It - Important) , crisis planning in advance

• Is it possible to populate clinical info for plan – blood test (Post It - Streamline + assimilate documentation)

• Keep under review – arrangement (TRIGGERED BY PLAN) agreed with individual/family (Post It –Care pla i g for u its ouples . Pla for o ti ge ies

• The Plan - Common format + electronic + can be shared AND Printed summary for individual which is meaningful to them (Post It – That needs to follow them acute/community

4. Multi-disciplinary teams

(MDTs)1. Key transformation

– A) Key service at relevant stage Fluid• Simple to navigate & Access – Patient & professional

• Flagged

– B) Patient care is coordinated

– MDT has to be PATIENT specific and adapt/evolve

– MDT is a virtual team

– Confidentiality to cover all early in process plus shared /consent• ? Do all queries come here? When it just become a layer?

– Post It – Not sure that acute should be key service (part of it?) – This role should be retained by other community provider • This post IT was questioned by group

• Example – chemo / mac follow in/out

4. Multi-disciplinary teams

(MDTs)4. Voluntary and community

– K o i g hat’s a aila le– Recognising their skills and knowledge

– Be involved in MDT

– Have access to information

5. 24/7– “hould e Care . O e ord

• MDT– Formal process where appropriate

– Explore mental health model

– Clear contingency plan identified at Single Point of Access

5. Care coordination as a specific

role in the MDTFirst Point of contact responsible for care support plans including specialist care liaison

1. Key transformation – Persons journey more simplified

– Less risk/harm – decrease safeguarding

– Improved admission avoidance

– Reduction in non-elective admissions

– Improve patient care

– Build trust & relationships – Improve patient outcomes

– Reduce social isolation

– Early identification

– Escalation plans

2. Operate– Inclusive of physical and mental health, social services, voluntary sector, independent sector,

community support services

– Establish links across the wider system

– Role out integrated teams

– Joint working

– Patient centred car

– Who will be in team

– Enhance of what already exists e.g. include Consultant Geriatrician

– Escalation plans plus individualise care/support plans


role in the MDT3. Skills and Roles

– Organisational skills

– Communication skills

– Expertise & knowledge of system]IT Skills

– Identify crisis/intervention

– Add co-ordinator into title

4. Voluntary and community– Include voluntary sector

5. 24/7– All professions using different models

– Enhance existing services

– Cut core hours & increase out of hours options

– Coordinator to have access to all professionals & systems

– Incorporate 111 service

6. Colocation– Out of hours

• Social services

• Community

• Etc.

– Dial in options


role in the MDT7. Technology

– Tele health

– Tele care

– Sensory needs

– Coordinated response 24/7

– Signposting options

– Escalation plans

8. Transport implications in the model– 24/7 transport links responsive to patients needs

– Role of voluntary sector

– Family / friends / neighbour involvement

9. Do you have any other observations– First 2 days important and prevent crisis and escalation

– Fluid responsive

– To include single point of access function

Care Act: Reforming Care & Support

Nick Ireland

Adult Social Care, Health & Housing

NATIONAL CONTEXT – Demands on the System

CARE AND SUPPORT: Demands on the system

• Three-quarters of people aged 65 will eventually need care and

support in their later years: Increasing demographic

• Older people are the core users of acute hospital care - 60% of admissions, 65% of bed days and 70% of emergency

readmissions.

• 72% of recipients of social care services are older people,

accounting for 56% of expenditure on adult social care

What is the Care Act?

• Biggest change in Adult Social Care legislation for 60 years,

following the recommendations of a three year review by the

Law Commission

• Reforms the law and funding regime relating to care and

support for adults and carers

• New legal framework - brings legislation together into one

modern law

• Integration with health runs throughout the Act

The Care Act 2014 replaces many previous laws

What is the Act trying to achieve?

That care and support:

• is clearer and fairer (national eligibility criteria)

• promotes people’s wellbeing• enables people to prevent and delay the need for care and

support, and carers to maintain their caring role

• puts people in control of their lives so they can pursue

opportunities to realise their potential (personal budgets)

• supports integrated and co-ordinated care

The framework of the Act and its statutory

guidance

The wellbeing principle

• ‘The general duty of a local authority,….in the case of an individual, is to promote that individuals well being’’.

• Wellbeing broadly defined: personal dignity, health, control in day to day life, relationships, access to work, support before crisis develops

• Local authorities should also have regard to other key principles when carrying out their activities, such as beginning

with the assumption that the individual is best-placed to judge

their well-being

New responsibilities of local authorities towards

all local people

• Arranging services or taking other steps to prevent, reduce or delay peoples’ needs for care and support

• Provision of information and advice, relating to care and support for adults and carers as well as where people can get

independent financial advice about how to fund their care

• Promoting diversity and quality in the market of care

providers so that there are services/supports for people to

choose from

New duties – integration and market oversight

• A statutory requirement to collaborate and cooperate with

other public authorities, including duty to promote integration

with NHS and other services and deliver joined up care.

• Duty for local authorities to step in to ensure that no one is left

without the care they need if their service closes because of

business failure

• Duty to ensure a wide range of care and support services are

available (working with community partners)

New duties – advocacy, safeguarding and transitions

• A duty to arrange independent advocacy if a person would

otherwise be unable to participate in or understand the care

and support system

• First statutory framework for protecting adults from neglect and abuse. Duty on local authorities to investigate suspected

abuse or neglect, past or present, experienced by adults still living and deceased

• Duty to assess young people and their carers in advance of

transition from children’s to adult services, where likely to need care and support as an adult

What might this mean for people needing care and support?

• Better access to information and advice, preventative services,

and assessment of need

• An entitlement to care and support

• A cap on care expenditure which an individual is liable for

comes into effect from April 2016

• A common system across the country:

– Continuity of care

– Fair Access to Care Services (FACS) replaced by a

national eligibility threshold

What does this mean for carers?

• The Care Act strengthens the rights and recognition of carers:

– Improved access to information and advocacy should make it easier for carers to access support and plan for their future needs

– The emphasis on prevention will mean that carers should receive support early on and before reaching crisis point

– Adults and carers have the same rights to an assessment

– A local authority must meet eligible needs of carers and prepare a support plan

What might this mean for local authority partners and care organisations?

• NHS, housing and children’s services share the duty to

integrate

• Partners and providers will find:

- They need to respond to the wellbeing principle

- Greater local authority focus on promoting diversity and

quality in the market

- Greater local authority involvement in services focused on

prevention and delay

- National, not local, eligibility criteria

- New, statutory safeguarding arrangements

Summary

• A significant piece of legislation that modernises the framework

of care and support law, bringing in:

– New duties for local authorities

– New rights for people requiring support and carers

• It aims to make care and support clearer and fairer and to put

people’s wellbeing at the centre of decisions, and embed and extend personalisation and prevention

• Local authorities have new responsibilities towards all local

people, including self funders


Designing the component parts of the model - Round 2

Designing the component parts of the model -Round 2• Select which component you want to work on.

• Ensure all tables have the necessary people.

• Use your knowledge, research, experiences and design principles to answer the

questions on flipchart paper.

• Please clearly name the component on each page and the question numbers.

• Include the recorder’s email address.1. What is the key transformation the system component is being designed to

achieve?

2. How should the system component operate?

3. What skills and or roles must be involved to make it work as designed?4. How can you maximise the role of the voluntary sector and local community?

5. Which system components should be available 24/7?

6. Which system components should be co-located?

7. How can Technology or Assistive Technology support both the process and

person’s outcomes in this component?

8. Are there transport implications in the model?

9. Do you have any other observations for the design of this system component?

• Prepare and set up for Gallery Walk53

Designing the component parts of the model -Round 2

Gallery walk to review the component parts of the

model. • One person to remain at your station to explain the

component to visitors and add any updates.

• The rest of the table will move clockwise to the next station.

(5mins per station)

• Station visitors to challenge and improve component design –being mindful of design principles, research and experiences

to highlight any gaps / opportunities

• Once all components reviewed return to original groups and

debrief.

• Capture changes and amendments and finalise your design.

• Collate all model components together on one wall55

6. Enhanced (Integrated) services

for Localities1. Key transformation

– Difference between Multi Disciplinary Teams for Integrated Services

– How big localities means for what is locality

– What could be provided community integration

– Identify what currently exists in locality for what needs to enhance & avoid duplication

2. Operate– Shared Vision for localities

– Pooling resources together - all sectors• Join budget

• Co located

• IT systems

• Joint management

• Post IT - Seamless transfer

– Practice federations - Super surgeries Hub of integration including secondary care input

– Integration work started at Bracknell Forest Locality i.e. Single Point of Access, Multi Disciplinary Teams

6. Enhanced (Integrated) services

for Localities

3. Skills and Roles

– Staff for organisations buying onto model

– Single integrated paperwork with logos

4. Voluntary and community

– Involve voluntary sector in developing integrated

model for locality

– Commissioning

– * Link to Better Care Fund

7. Specialist and Hospital

processes (Acute)1. Key transformation

– Continuity of all services along patient journey – on admission and discharge

– Full access to shared integrated record

– Care co ordination to continue I hospital – or started if not in place (Post It – Notify GP!)

– Specialist Acute/Community availability pre/during/post admission – visit or phone access

– Speedy access to senior decision makers (Post It – Consultant oversight and advice 1 week post discharge)

– Swift access to appropriate services on discharge – Pooled budget?

– Team within hospital (specialist) to support with co-ordination of patient journey in hospital + point of access for key worker service


processes (Acute)3. Skills and Roles

– Geriatrician to be involved (identification) in all from admission (more geriatricians)

– *24/7 access – Acute community to geriatrician

– All frail patients to have a CGA with geriatrician Review

– Acute & Community specialists to in-reach/outreach

4. Voluntary and community– Continuity of services on admission

– Increase role on discharge

– Increase awareness of acute on what is available

– Welfare checklists on discharge

– Post It – Risk Ad isor li e, GP’s!!5. 24/7

– See *

6. Technology– Integrated shared record


processes (Mental Health)1. Key transformation

– Increasing Awareness across agencies + older people + communities

– Improving identification = diagnosis + or other conditions/life circumstances that affect Mental Health (Post It – How to Integrate. Co e t was that does ’t feel i tegrated at moment)

– Improving Integration Example HTT + ICT*. Better Understanding

– Better Access – older people (IAPT) / Equitable / Resource Capacity (Post It – Integration with Out Of Hours)

– Improved multi-agency knowledge of persons – diagnosis / other conditions* (Post It – Wexham Park Hospital insufficient M/J support (NB OPMHQ has just expanded))


processes (Mental Health)3. Skills and Roles

– Practitioners better knowledge/understanding e.g. communication strategies + preventions

– Care planning process – Co-ordination person centred + meaningful to the individual

4. Voluntary and community– All levels support + process * co-location or pathway clear

5. 24/7*– Key

7. Technology– Key

– Post It – Media to increase awareness of safer places & Dementia Friendly (forget me not)


processes (Mental Health)

• Mental Health Admission

– Same key elements as Acute (Table B)

– Not an isolated episode (care + support at home does ’t stop

– An older persons liaison service that works across physical + mental health

– Communication / continued care planning when admitted

– Coordinated discharge with Multi Disciplinary Team / Coordinator

9. Primary Prevention

• Everyone's business

• Frailty assessments / early identification

• How do you make what is out there accessible / affordable

• Reactive care – when link with services

• Proactive care – call in/identity those not seen

• Patient ownership – raise profile advertise frailty how to self assess

• Support with choices, ensure informed

• Health improvement within restriction social isolation / poverty / housing / oral health


How?

• Post it – Effective escalation plan

• Tool – Multi factorial assessment individual / group led

• Identify– Triggers – fall

– Self referral

– Risk strategy tool

– Contact with any friend, family, professional, community• Clear plan – What do they do with concerns?

• Advertise– Raise profile – National Drive

– Leaflets/word of mouth


• Social links – Clubs + day centres

– Mindfulness sessions

– Employers

– Schools

– Transport

– LTC café

– Silver line (=child line)

– Cultural barrier – How do you make it acceptable to mitigate frailty (Post It – Informal carers – elderly husband looking after / elderly wife – What happens when this falls down?

• Support + signposting

• Multi assessment program including social/mental needs

• Community – review environment + transport that restricts + disables

• Health Wat h – Voluntary, checking on individual identified – Out reach

– tool + plan what to do next

Lunch

66


The Emerging Model

The emerging model

Zoom out - do the components fit and flow together as a whole

system?

Consider the questions below on your own for 2 mins, then discuss your thoughts with 3-4 others for 7mins. Finally we will discuss these and other insights in plenary for 15mins.• Where are the critical connections between the components?• How can we ensure the critical connections and interdependencies are

made?• Are the components aligned? • Are there any gaps?

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The emerging model - Plenary

• More focus back on Acute sector = improvement

• Concern on looking at individual components = reduced integration & duplication creeping in / overlaps

– MDT and integrated care teams, Single point of access, care coordinator team

• Resources – How are we going to afford the transformation– Reduction in patients through front door to close beds

– Consider the phases of implementation

• Need to break the circle of patient Acute who then keep the beds open which means people Acute. Then shift resource into the community

• Some of this work is happening in our organisations, we need to build on assets, link, align and scale up, agreeing principals will help us

• Build on emerging assets in our systems, watch out for unintended consequences

• What happens when an informal care arrangement breaks down? Joint care plan always planning for contingency.

• Post It’s– Ca ’t desta ilise rest of populatio for frailt– Build all assets – Watch out for unintended consequences

– Some work happening already – need to expand implementation will be easier

– Resources


Interoperability – Shared Recordsa key enabler for the new model of

care

Our PartnersThis is a Berkshire East project but similar is

underway in Buckinghamshire

Patient Care

GP

Acute

Out Of

Hours

OtherCSAS

Community

& Mental

Health

Social

Services

Slough Council

Bracknell Forest

Windsor & Maidenhead

Frimley Park

Heatherwood & Wexham

Royal Berkshire

Berkshire Healthcare

East Berkshire (OOH)

St Mark’s UCCBracknell (UCC)

Slough (WIC)

Patients

Pharmacies

Independent Providers

Charities, Police, Schools

Central Southern

Ambulance

50 GP Surgeries

Share Your Care• Project commenced September 2014

• Phase 1– Complete – Primary Care data now shared with Out of

Hours, Urgent Care Centres and Slough WiC

• Phase 2– Summer 2015 - Pilot sharing primary care, community care

and social care data with Integrated Care Teams, EOL and ambulance services.

• Phase 3– Procurement to launch September 2015 for full system

portal

Sharing information in this way brings challenges with Information Governance which must be resolved

Preparing for the Procurement

• Phase 3 tender will be via a framework with about

17 leading providers of Interoperability systems

• Systems are Commercial Of The Shelf (COTS)

products – we are not building from scratch.

• Tender process needs to test

– Fit with our detailed requirements

– Demonstration of delivery

– Vendor capacity and capability

– Value for money

Fit with our detailed requirementsThe Requirements Specification – filters to a shortlist

FUNCTIONAL

• patient consent model

• legitimate relationships

• managing patient details

• patient identification, patient lists & data presentation

• alerting, notification & messaging

• care planning

• integration with existing systems & decision support

• terminology services

• results reporting

• patient portal

Fit with our detailed requirements 2

OPERATIONAL

• auditing

• access control

• user and password management

• session management

• data quality management

• local configuration management

• help documentation

• clinical safety

• clinical repository (bi)

• miscellaneous

Fit with our detailed requirements 3

TECHNICAL

• architecture and platform

• messaging

• data migration

• device access

IMPLEMENTATION

• implementation and support services

• scope management

• benefits realisation

• service management

Detailed Requirements will produce a shortlist

of 3 or 4 who will be required to actively

demonstrate the functionality of their System

• This is a critical part of the procurement and we are asking for your help to get it right

• Our scenarios will concentrate on

– Care for elderly citizens

– Safeguarding children

• Today we will be looking at the care for elderly citizens scenarios which are based on an e te ded “a ’s stor

An AskWhen we move to the provider demonstration part of the procurement process we will be taking 3 – 4 providers through a rigorous process.

Each demo likely to be at least half a day

Site visits also envisaged

We need well informed members of the front line to help us in the selection process.

As members of the design team we will be writing to you in due course to invite you to take part.

If you would like to volunteer today please give your details to Anshu Varma

Sam’s story – our approach

• We created a complex patient journey

• We have spoken to front line staff at key points on that

journey to establish

• Current issues

• How interoperability could deal with those issues

GPScenario 2

SpecialistScenario 6

OOHScenario 3

A&EScenario 7

HomeScenario 1

WardScenario 8

O/PScenario 9

AmbulanceScenario 5

“a’s

Jour

e

Social CareScenario 4

1&2. Age Well/Live Well 3. Complex co-morbidity 4. Crisis Support 5. Acute admit/IP Care 6. Discharge 7. Independence 8. Quality Care 9. Planned Care

* See Appendix 1 for an example

The Exercise• Sam's story was sent out before the workshop,

additional hard copies are on your tables

• On posters in the room are the reports back from front line staff– The scenario

– The issues

– What staff believe to be the solution

• In 5 chapters1. Emergency

2. Discharge and the community

3. Oncology treatment

4. Sam has a fall

5. End of life

Scenarios are grouped into 5 chapters

so please work in 4 groups to answer

the following questions

• Chapters 1 & 5 will be on the same table, each other table will cover the other chapters.

• In looking to solve todays problems are we providing what the new model needs?

• Having looked at the episodes in the pathway is there something more we need at a system level?

• Round robin feedback in plenary.

Interoperability - plenary

• All relevant parties need visibility of records

• Information needs to real time

• Coordinated approach across the systems

• Contingency for system failure

• Visibility of patient record to access full medical record

• Live communication tool for contextual information

• All IT systems need to be able to talk to the portal

• Care planning completed early so visible to all services

• Communication with international relatives

• System alerts and parameters

• Flag concerns when patients transferred from one service to another

• Refer through the portal

• Maintain high standard of data quality

• Not a replacement for conversations

• Intelligent information when we need it – not pushed all the time to everyone

• Aligned communication between professionals

• Discharge summary on USB

• Pre-planning with a care coordinator

• Seamless care between services e.g. discharge to community

• Txt alert to access secure system

Care Act – plenary

• Need to align all programs across whole

system to have an integrated approach

– Representatives at/on all programs to link + align

– Use big conversation

– Feel empowered to discuss this in your

organisations

Break

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Articulating the Model

Articulating the model

To be able to articulate clearly the benefits of the Care and Support Model to the

public, your colleagues and other stakeholders.

Each “perspective” group to create a 3 minute pitch to either the public or to your colleagues.

Your aim is to get them to invest in the model - be creative in your pitch!

1. Pitching the model to the public▪ I really like this model because…▪ The difference it will make is…

2. Pitching the model to your colleagues▪ The benefits for us are…▪ The difference it will make is…

30minutes to prepare.

3 minutes to pitch! 89

Final plenary

Attendees expressed that they:

• Were confident with general vision

– Front end clear

– Medical back end model needs working through

• Need to clarify what to do in the next 6

months, milestones etc.

• Need to look at prioritising components


The Story so Far

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• Design Group Workshop 1 26th March

Patient Group Conversation 16th

April

• Design Group Workshop 2 30th April

Patient Group Conversation 14th

May • Design Group Workshop 3 28th May

System Review 30th June

Discussion via Health Connect throughout

Next steps

Review and Close

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Collaborative Care for Older Citizen - DIY Review

1. To what extent did the workshop meet your expectations? 8.1 /10 (10=high)

2. What were your key learning points from today? (thematic examples)• There is agreement across the system in the future model of care

• This was just the beginning of a long process of change

• Not simple thing to do - next steps are vital. Good method of consolidation with Dragons Den

• The design model looks possible with input from all

• Voluntary sector input

3. Could the process of the day be improved in any way? (thematic examples)• More emphasis on the how

• It is good but heavy

• No, very focussed but enjoyable

• Only with more time!

• We reactivated the 2nd workshop

4. Any other comments or information required? (thematic examples)• Useful Workshops - V. Stimulating

• We didn’t move forward very far. We are still saying what we want not what can we afford who will delver etc. But overall I think the model does provide a good starting point.

• More input from voluntary sector

• Clear communication about next stages

• Third workshop was best - brought us closer to solutions

collaborative care for older citizens · 2019. 11. 19. · • getting to know each other exercise...

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