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Long term conditions

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  • 1. Jude Smith Respiratory Nurse Consultant & Long Term Condition Lead 24 th March 2011 Transforming Community Services LONG TERM CONDITIONS personalised  responsive  effective  innovative
  • 2. Background
    • As part of Transforming Community Services, Leicestershire County and Rutland Community Health Services intended to provide a model of integrated, streamlined care for patients with Long Term Conditions (LTC)
    • A key part of this model was the development of a LTC Hub to bring together all health professionals involved in the care of people with a LTC under one integrated service.
    personalised  responsive  effective  innovative
  • 3. What is a Long-Term Condition Hub?
    • Not just a SPA
    • Hub and spoke
    • Integrated patient management service
    • Brings all patient generic tasks together in one place- freeing up clinician time
  • 4. Current Situation personalised  responsive  effective  innovative Administration
    • Multiple communications (calls, emails, referrals, faxes, letters, etc) to and from all LTC staff, resulting in less time to care
    • Clinical staff are pulled away from core duties by administrative tasks
    • Over-dependence on individuals being available
    • Low levels of administrative support
    GPs Hospitals Patients Community Teams Consultants Social/ Voluntary Care LTC Clinicians / Community Matrons
  • 5. Future Plan personalised  responsive  effective  innovative LTC Hub
    • Streamlined communications to and from LTC Hub, supported by clinical triage
    • Full administrative support for clinicians, resulting in more time to care
    Triage GPs Hospitals Patients Community Teams Consultants Social/ Voluntary Care LTC Clinicians / Community Matrons
  • 6. Key Features (current thinking)
    • Hub open Mon – Fri 9am to 5pm, with enhanced OOH support from existing OOH team
    • Manned by c.6 Case Coordinators
    • Located in Fosse House, from late Oct/early Nov 2009
    • Dedicated telephone numbers for patients and professionals
    • Clear, documented processes (care pathways, referrals, call handling, data entry, diary management, hand-offs, correspondence, service level targets, etc)
    • Two clinicians within the Hub each day (approx. one working day in seven). One will focus on triage, the other will support triage activity and have ring-fenced admin. time.
    personalised  responsive  effective  innovative
  • 7. Key Benefits
    • Improved access to LTC team for patients and professionals, especially when staff are away (holiday, training, etc)
    • Reduced administration for LTC clinicians/CMs – more time to care
    • Better use of Trust resources. Streamlines patient services
    • Increases productivity of clinicians
    • Promotes integration both internally and externally
    • Brings accountability of service delivery from the point of referral
    • Increases cost-effectiveness
    personalised  responsive  effective  innovative
  • 8. Steps we took
    • Staff engagement process in August 2009 to inform future service delivery, followed by 30 day Consultation Period
    • Design and build of Hub
      • Recruitment and training of Case Coordinators
      • Cross-training of clinicians (subject to service design)
      • SystmOne enhancements
      • Process design
      • Capacity planning (across all LTC roles)
      • Communication programme (to GPs, hospitals, etc).
    personalised  responsive  effective  innovative
  • 9. Screen, Diagnose Optimize Care Case manage Acute response Care co-ordination Specialist interventions End Of Life General Practice Community Teams Secondary Care Social Care
    • LTC Hub
    • Admin
    • Referral management
    • Workforce development
    • Team management
    • OOH
    COPD HF Diabetes Neuro Complex Elderly EOL
    • Referrals to
    • GP
    • Community teams
      • DN
      • Intermediate Care
    • Social Care
    • Secondary Care
    • Case Finding
    • Health Utilisation
    • VHIU
    = MDT Review
  • 10. Implementation
    • Project title: LCR CHS SPA/LTC Hub Project Manager: JP
    • Report coverage: Week ending 23.10.09 Update number: Status Report 4
    • Overview Project Status GREEN AMBER RED
    • Workstream Milestones and key tasks completed for week ending 23.10.09
    • Project Management Updated detailed action plans
    • HR, Recruitment and Training
    • Assessed initial (four) responses to Service Coordinator secondment positions (from LTC admin. & OOH)
    • Email sent to wider PCT advertising Service Coordinator secondment positions to generate more candidates. To date this has generated one definite candidate, with possibly one more
    • Further discussion re. scope of change for LTC clinicians (shift hours when in Hub)
    • SystmOne refresher training for clinicians
    • Updated training requirements, and commenced population of training material
    • Processes & MISRecalculated capacity plan for LTC clinicians
    • Reviewed Adastra requirements for LTC patients (call logging, special patient notes, reporting)
    • Communication
    • Prepared patient pack for sign-off
    • Attendance at strategy group (Noel O’Kelly) to identify best approach to GP community
    • Progressed copy for CHS magazine and intranet
    • IT & Telephony
    • Reviewed call routing/numbering for LTC patients into the SPA/Hub
  • 11. Implementation
    • Good News Nothing new to report
    • Issues/Risks arising this week
    • Providing basic LTC patient data to OOH, EMAS, etc identified as a risk as it may breach patient confidentiality. This will be reviewed in conjunction with Information Governance.
    • Milestones and key tasks planned for week commencing 26.10.09
    • Project Management
    • Update project and strand plans
    • HR, Recruitment and Training
    • Assess PCT responses to Service Coordinator secondment positions
    • Initial discussions with candidates for Service Coordinator secondment positions
    • Finalise scope of change for LTC clinicians (shift hours when in Hub)
    • Confirmation of level of LTC training required for SPA nurses
    • Complete and submit Management of Change paper
    • Commence consultation process with existing LTC clinicians and administrative staff
    • Training design meeting, and further population of training material
    • Processes & MIS
    • Complete call handling script
    • Formatting of key Hub processes for formulation into handbook
    • Confirm that Adastra requirements for LTC patients can be delivered
    • Further review of dataflow requirements/feasibility
    • Review of Rotamaster as possible tool for scheduling LTC clinical cover
    • Communication
    • Alter patient pack to reflect decisions on phasing the service
    • Progress copy for CHS magazine and intranet
    • Meeting to introduce Hub to EMAS etc on 29th October
    • Noel O’Kelly to update project on approach to GP communication
    • IT & Telephony
    • Confirm call routing/numbering for LTC patients into the SPA/Hub
  • 12. Implementation- KPI’s
    • Heart Failure
    • Reduced mortality rate
    • Patient satisfaction
    • Avoidance of hospital re-admission
    • Number of hospital admissions
    • Number of patients on the correct medication
    • Patients are managed in accordance with national guidelines e.g. NICE
  • 13. Communication
    • Mailing Action Who By
    • PATIENT MAILING (Approx. 1,800)
    • Manage agency to print letters, leaflets, ID card 23rd November
    • Manage agency to attach ID card to letter 23rd November
    • Manage agency to stuff letters and leaflets into envelopes, and deliver to Fosse House 26th November
    • Ensure that LTC patient database is accurate, and printed onto address labels (in a CHS site) 26th November
    • Arrange for CHS staff to attach address labels (must take place in location that address labels are printed) 30th November
    • Arrange for Fosse House post room to frank and post letters, and post out 2nd Class on 2nd December 2nd December
    • GP MAILING
    • Write GP letter, and get it proofed and approved 26th November
    • Manage agency (or internal dept) to print letters and posters 27th November
    • Manage agency (or internal dept) to stuff letters and posters into envelopes, and deliver to Fosse House 30th November
    • Ensure that GP database is accurate, and printed onto address labels (in a CHS site) 30th November
    • Arrange for CHS staff to attach address labels to envelopes (must take place in location that address labels are printed) 1st December
    • Arrange for Fosse House post room to frank and post letters, and post out 2nd Class on 2nd December 2nd December
  • 14. Staff rota   NWD NWD NWD X   NWD NWD X     Heart Failure NWD   NWD H   NWD   NWD   X NWD Heart Failure     HA X UNI   AL AL AL AL AL Heart Failure   X   X X   X   X X X Heart Failure   NWD NWD   H   NWD NWD X SL   Heart Failure NWD     NWD NWD NWD NWD NWD NWD   X Heart Failure   X X     HA X X X X X Heart Failure           H           Diabetes             HA         Diabetes NWD NWD       NWD NWD H     NWD Diabetes H                 HA   Diabetes   NWD H       NWD       HA Diabetes     X         HA   X   COPD AL NWD NWD NWD     NWD NWD NWD     COPD X X X X AL AL H X X X AL COPD   H X   X X X X HA X X COPD   X X X X   X   H     CM       X HA           H CM HA     X           H AL CM
  • 15. Clinician capacity plan
  • 16. The Launch
  • 17. The Launch
  • 18. The Launch
  • 19. Where we are now
    • 160 calls per week Patient LTC line and HCP line
    • 95% of calls answered in <60 seconds
    • Average speed 0.26 seconds
    • 3002 referrals year to date
    • Management of change process
    • Reduction of staffing 1.2 wte HF, 2.0 wte Resp, 8% of DSN time
  • 20. The Future?
    • Platform for telehealth
    • Extending the hub for other services
    • PBC