Moving to 7 Days Services in Dudley

Paul Maubach

Chief Accountable Officer

Dudley CCG

Local Dudley Service Provider

‘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’

Deaths by Day in Dudley - 2012

Weekday Deaths Day Count

Average Deaths per

Day

Sunday 400 53 7.547

Monday 411 53 7.755

Tuesday 396 52 7.615

Wednesday 396 52 7.615

Thursday 420 52 8.077

Friday 436 52 8.385

Saturday 398 51 7.804

Grand Total 2857 365 7.827

Strategic Priority

Privileging Population Health and Wellbeing

• Autonomous individuals

– Preventing / resolving dependency

• Registered population

– Aligned, networked service delivery

• Mutual responsibility

– Understanding the value of what we do

– Sharing our social capital as a community

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.

Dudley Health and Social Care Economy – The Opportunity

Unnecessary emergency admissions

Excessive service usage by over 80s

Too many admissions to nursing and residential care

Recognition by partners of the need for a step change in service delivery

Commitment to redesign urgent care

Evidence that 5 day working creates dysfunctional service pressures

7 day services: variation in delivery

-15

-10

-5

0

5

10

15

20

Mon Tue Wed Thu Fri Sat Sun

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…..

Person

GP Practice

Community

Clinical Commissioning

Group

Registered Member

Based in a Locality

Part of a System

Aligned, Networked Population Health and Wellbeing Services

Integration and 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

Dudley was successful in applying to be one of the National Early Adopters

Cross health economy working group set up

Working with NHS Improving Quality Team

Three main areas of focus

Mapping of services

Developing community standards

Sharing best practice with other early adopters

7 day services

Community Mental Health Teams: adults

and older people

Palliative care team

Heart failure-joint pathway

with acute

OT

Physio

Care home nurse

practitioners

Stroke

Neurology

Social 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

1. Patient experience 2. Integrated team review 3. Information and communication 4. Diagnostics 5. Speed of access and assessment in the

community 6. Mental Health 7. Quality Improvement 8. Palliative and End of Life

Community Standards

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

Team of 9 Advanced Nurse Practitioners

Integrated with social care assistants and care home nurse practitioners

ANPs take a referral or intercept 999 green code call

Assess, diagnose, initiate treatment, instigate social care package if required and step down to integrated teams

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 Practitioner

Within one hour

Step down to Locality Integrated Teams

Single Point of Access for Advanced Nurse

Practitioner Based at WMAS

Admit to

EAU

- Initiate treatment →

- Initiate care package → up to 7 days (then review)

- Initiate care plan

Practice integrated teams To consist of GP, pharmacists,

community nurses, named social and mental heath workers. To review risk stratification tools and agree a Care Coordinator for complex cases

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

Service Integration

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

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

Single point of access

Develop self care programmes

Develop remote monitoring tools (tele-health)

Increase utilisation of voluntary sector (community link workers)

Social prescribing

Prevention agenda

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2.00

3.00

4.00

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ACG Probability of Future High Cost

Actual Avg no FHS

Actual Avg no OPAs

Actual Avg no AE Attendences

Risk Stratification

Identification of risk using ACG tool

MDT Care Planning

Care gap

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

Mobile technology

Representative approach: Patient perspectives a standard item on the integrated

working group Aim is to capture the actions and improvement that need

to be implemented. Feedback given to the patient, carer or advocate that

provided the story/experience.

Participative approach: Development of systematic tool (PSIAMS) to record the

patient experience of care Enables patient to chart their progress against outcome

goals

Learning from patient experiences

The Overall Purpose is: Improve patient experience, and their health and well being outcomes Improve patient engagement, to increase their autonomy to take control

over their own care. Develop collaborative relationships between patients & integrated teams. To improve collaboration and cross-boundary working between

organisations. To work towards a culture change, that demands values based care, and a

can-do attitude. The Specific task is: To address the issues of complex cases demanding multi-agency

approaches Mutual Networked Leadership, shared population, shared outcomes

Leadership programme

Strategic Priority

Privileging Population Health and Wellbeing

• Autonomous individuals

– Preventing / resolving dependency

• Registered population

– Aligned, networked service delivery

• Mutual responsibility

– Understanding the value of what we do

– Sharing our social capital as a community

Questions?