Your SlideShare is downloading. ×
0
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Acute and community services "Integrators of Care"
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Acute and community services "Integrators of Care"

2,411

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
2,411
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
24
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • North Tees and Hartlepool NHS Foundation Trust was established in December 2007 and provides healthcare services to a population of approximately 400,000 people in part of the North East of England. (slide with map). It covers an area from Easington in Durham in the North, Stockton in the South, Hartlepool in the East and parts of Sedgefield in Durham to the West. Service provision encompasses a wide range of health services covering some specialist acute services, a wide range of acute general hospital services, outreach services into community settings and, since 1 November 2008, the Foundation Trust has been hosting the full range of community services formerly provided by NHS Hartlepool and NHS Stockton-on-Tees. The organisation employs in excess of 5500 staff including the 800 in the hosted community services and has an income of c£230M.
  • Transcript

    • 1. Community Services – Beyond Transfer to Transform Acute and Community Services “Integrators of Care” Linda Watson, Clinical Director of Community Services Carole Langrick, Deputy Chief Executive/Director of Strategic Development
    • 2. Community Services – Beyond Transfer to Transform Presentation will cover: <ul><li>Who we are </li></ul><ul><li>What we did and why in relation to vertical integration </li></ul><ul><li>Outline the progress in 6 key areas of integration </li></ul><ul><li>Illustrate the ways in which our model has enhanced patient care </li></ul>
    • 3. Who are we? <ul><li>Provide healthcare to 400,000 people in Easington, Stockton, Hartlepool and Sedgefield </li></ul><ul><li>Foundation Trust since December 2007 </li></ul><ul><li>Have two major hospital sites in Stockton and Hartlepool </li></ul><ul><li>Work from 38 community sites </li></ul><ul><li>Employ 5,500 staff including 1200 in community services </li></ul><ul><li>Have a £230m annual budget </li></ul>Community Services – Beyond Transfer to Transform
    • 4. Why did we do it? Community Services – Beyond Transfer to Transform
    • 5. Community Services – Beyond Transfer to Transform What did we do? <ul><li>PCTs transferred community services to the Foundation Trust on 1 st November 2008 </li></ul><ul><li>Contract extended to June 2011 </li></ul><ul><li>Underpinned by legal agreements </li></ul><ul><li>TUPE transfer for staff </li></ul><ul><li>PCTs retained premises and assets </li></ul><ul><li>Foundation Trust to maintain services, staff and all other arrangements throughout duration as they were at point of transfer </li></ul>
    • 6. Community Services – Beyond Transfer to Transform <ul><li>Currently 60% of patients die in hospital, 20% at home, 15% in care homes, 5% in Hospice </li></ul><ul><li>Future 60% would prefer to die at home </li></ul><ul><li>Would you be surprised? </li></ul><ul><li>24/7 1 hour responsive care </li></ul><ul><li>GSF for Care homes </li></ul><ul><li>Information exchange </li></ul><ul><li>Advance decisions to refuse treatment </li></ul><ul><li>Prognosis to bereavement </li></ul>Transforming Services: End of Life Care
    • 7. Community Services – Beyond Transfer to Transform Current State <ul><li>Multiple locations across Hartlepool and Stockton </li></ul><ul><li>Two different service models </li></ul><ul><li>No standard referral criteria </li></ul><ul><li>Education provision is disjointed </li></ul><ul><li>Disjointed communication </li></ul><ul><li>Limited peer support </li></ul><ul><li>Good relationships with generalist health and social care staff </li></ul>
    • 8. Service development Service development Service development Service development Clinical supervision Clinical supervision Community Macmillan Nurses x 2, Macmillan Secretary x 1 (P/T) Phoenix Centre Referrals Strategic meetings Consultant in Palliative Care x 1, Macmillan Nurse x 1 Secretary (P/T) UHH Macmillan OT x 1, Macmillan Physiotherapist x 1, Palliative Care OT x 1 Hartlepool Hospice Education Audit Community Macmillan Nurse x 1 Masefield Road Community Macmillan Nurse x 1 Masefield Road Strategic meetings Strategic meetings Strategic meetings Strategic meetings Strategic meetings Referrals Referrals Referrals Referrals Referrals Referrals Audit Audit Audit Education Education Macmillan OT x 1, Macmillan Physiotherapist x 1, Macmillan OT Technician x 1 Lawson Street Stockton Community Macmillan Nurse x 1, Billingham Health Centre Consultant in Palliative Care x 1, Nurse Consultant in Cancer and Palliative Care Macmillan Nurse x 1 Secretary x 1 (P/T) UHNT Community Macmillan Nurse x 1 Eaglescliffe Community Macmillan Nurse x 1, Stockton Community Macmillan Social Worker x 1, Billingham Council Offices Referrals Referrals Strategic meetings Strategic meetings Referrals Audit Audit Education Education Macmillan CNS Referrals Audit Referrals
    • 9. Hartlepool Consultant in Palliative Care x 1, Macmillan Nurse x 1 Secretary (P/T) Community Macmillan Nurses x 3, Macmillan Nurse for care homes x 1 Macmillan OT x 1, Macmillan Physiotherapist x 1, Palliative Care OT x 1 Secretary x 1 (P/T) Strategic meetings Referrals Audit/Research Education North Tees Consultant in Palliative Care x 1, Nurse Consultant in Cancer and Palliative Care x 1 Macmillan Nurse x 1 Secretary x 1 (P/T) Community Macmillan Nurse x 3, Palliative Care Nurse for Care Homes x 1 Macmillan OT x 1, Macmillan Physiotherapist x 1, Macmillan OT Technician x 1 Community Macmillan Social Worker x 1, Referrals Strategic meetings Referrals Education Referrals Service development Clinical supervision Audit/Research Education New SPC team structure
    • 10. Service Delivery Expectations Community Services – Beyond Transfer to Transform <ul><li>100% of people who identify their preferred place of care will achieve that aim, where clinically appropriate and family are involved </li></ul><ul><li>100% of people requiring specialist palliative inpatient care where appropriate, will receive it </li></ul><ul><li>100% of carers requiring access to appropriate support will receive it </li></ul><ul><li>100% of carers will have their bereavement support needs assessed and will be signposted to appropriate support </li></ul><ul><li>100% of people dying in the hospital setting will have their end of life needs assessed and addressed </li></ul>
    • 11. Transforming services: Intermediate Care and Reablement <ul><li>Creative whole systems pathways of care and support </li></ul><ul><li>Excellent interagency partnership working – but can improve </li></ul>Community Services – Beyond Transfer to Transform
    • 12. Intermediate Care and Reablement Current State Intermediate Care Rapid Response Community Stroke Falls Team OT’s Physiotherapy Assistants Reablement workers Rapid response Nurse HCA’s OTs Physiotherapy SLT Dietician Psychology Assistants Coordinator OT’s Physiotherapy Assistants Emergency Care Therapy and Acute Teams and RASWS Community Services – Beyond Transfer to Transform
    • 13. Transforming Services: MSK Services <ul><li>Further integration </li></ul><ul><li>Step change reduction in GP referrals to Orthopaedics </li></ul><ul><li>Higher surgical conversion rates when referred on by MSK service </li></ul><ul><li>Health economy savings realised </li></ul>Community Services – Beyond Transfer to Transform
    • 14. <ul><li>The Purpose of the Managed Care Team </li></ul><ul><li>To use the Community Virtual Ward concept to ensure that there is a </li></ul><ul><li>philosophy and culture of sustained improvements and innovation to </li></ul><ul><li>deliver savings through improved care for patients with LTC, the frail elderly and those at risk of readmission within 30 days. </li></ul><ul><li>To act as a co-ordinating group to ensure that patients receive efficient and </li></ul><ul><li>productive services that enhances both the quality and safety of </li></ul><ul><li>care. </li></ul><ul><li>To ensure a systematic approach for patients who are ‘at risk’ of </li></ul><ul><li>admission and readmission to hospital across North of Tees. </li></ul>Community Services – Beyond Transfer to Transform Transforming Services: Community Virtual Ward
    • 15. <ul><li>Prevention of preventable admissions </li></ul><ul><li>Reduced LOS by improved discharge planning </li></ul><ul><li>Increase preferred place of care for patients with LTC to actively manage their condition </li></ul><ul><li>Development of integrated pathways across provider services </li></ul><ul><li>Appropriately trained workforce to deliver the right care in the right place at the right time </li></ul><ul><li>Improved evidence based outcomes for patients and staff </li></ul><ul><li>Provision of alternative cost effective solutions to healthcare delivery </li></ul>Community Services – Beyond Transfer to Transform Anticipated Outcomes
    • 16. Community Virtual Ward – Managed Care Pathway Managed Care Team (Single Point of Contact 24/7) Rapid Response, CM’S, DN’S, MDT, SOCIAL CARE (Primary Resources) GP Practices Acute Community Medical Support IT PCS Audit <ul><li>Patients triaged for suitability for Virtual </li></ul><ul><li>Ward admission. </li></ul><ul><li>Patients contacted by letter to offer services </li></ul><ul><li>Care plan developed following assessment. </li></ul><ul><li>Patients discharged to appropriate service </li></ul><ul><li>following period of care under managed care team </li></ul>Outcomes; improved quality, patient satisfaction avoidance to hospital, reduced admissions Patients identified using PARR ++ GP Practice to gain consent from patient to refer for Managed Care Supporting Departments Intermediate Care Specialist Nursing Tele-health Pharmacy NEAS Secondary care services Business Support Departments Admin Training
    • 17. Transforming Services: Improved Quality <ul><li>Peer review to measure quality </li></ul><ul><li>Senior nurses from primary &amp; secondary care undertake reviews – never in their own area </li></ul><ul><li>QRP undertaken in health centres, community clinics and patient’s own homes </li></ul><ul><li>Results of QRP are reported to Trust Board </li></ul>Community Services – Beyond Transfer to Transform
    • 18. Transforming Services: Staff Experience <ul><li>Infection Control – More robust protocols and checks and monthly audit control measures in our community clinics. </li></ul><ul><li>Stop Smoking Service </li></ul><ul><li>Networking between Acute and Community which improves working relationships and understanding of each others role. Opportunities for secondments to other areas. </li></ul><ul><li>District Nursing </li></ul><ul><li>I think altogether, we are settling into Community Service very well and we are all happy and proud to work for the FT. We certainly ‘fit’ better into the FT than the PCT as it now stands. </li></ul><ul><li>Health Trainer </li></ul>Community Services – Beyond Transfer to Transform
    • 19. Community Services – Beyond Transfer to Transform Thank you

    ×