12.20 anthony deery, northumberland, tyne and wear nhs foundation trust 27 feb
DESCRIPTION
TRANSCRIPT
Initial Response Team & Principal
Community Pathways
Anthony Deery
Nurse Director
Urgent Care
26th February 2014
Northumberland, Tyne and Wear
NHS Foundation Trust
• Population of 1.4 million people
in the North East of England
• Six geographical areas of
Northumberland, Newcastle,
North Tyneside, South Tyneside,
Gateshead and Sunderland
• One of the largest mental health
and disability organisations in
the country
• Income of circa £300 million and
circa 6,000 staff
• Over 130 sites and provide a
range of comprehensive
services including regional and
national specialist services
Initial Response Team
South of Tyne and Wear
REQUEST
FOR
HELP
ROUTING
ST UCT
OPS
LD
ICTS
SL UCT
OPS
LD
ICTS
GH UCT
OPS
LD
ICTS
Home Based
Treatment
Assessment
Gatekeeping
Home Based
Treatment
Assessment
Gatekeeping
Home Based
Treatment
Assessment
Gatekeeping
Information
Collection, Triage &
Routing
11
Gateshead
Rapid
Response
Nurses
11
South Tyneside
Rapid
Response
Nurses
11
Sunderland
Rapid
Response
Nurses
South of Tyne and Wear Model
Service User Experience Carer Feedback
GP Feedback
Wonderful
support! Brilliant team!
Fantastic – a huge
improvement!!
You should have
done it before
Staff Feedback
More
manageable
Skills are
valued
A lot happier Spend
more time
Yes No
Did the Initial Response Team meet your needs?
The Team were
excellent
keep this very
valuable service
going
Service Feedback and Evaluation of Pilot
Principal Community Pathways
A programme to design and implement new, evidence-based community
pathways for adults and older people.
Our ambition is high and is matched by the expectations of service users
and carers. The new pathways will:
• Significantly improve quality for the patient
• Double current productive time of community services by redesigning
current systems
• Enhance the skills of our workforce
• Improve ways of working and interfaces with partners
• Reduce reliance on inpatient beds and enable cost savings
This is not achievable in isolation and to be successful we need it to be part
of integrated work with partners
The symbiotic relationship PCP and Bed Model
Better
Community
Reduced
Beds
Money
available
Virtuous
Circle
Make
savings
£
£
Fewer
inpatients
Reduced cost
Poorer
community
More beds
than
realised
Less
Money
available
Vicious
Circle
Make
savings
-£ Not as few
inpatients
More cost than
realised £
Design Workshop
Workshop Product Specification
Scope Boundaries Principles Benefits People Constraints
Reasonable adjustment for pathway
Check
Does this meet the Product Specification?
Sign off
Ready to test
Design and Standard Work #1
Design and Standard Work #2
Gather data
Invite people
Refine
Week 0 Week 6 Week 7 Week 8
Check
Does this reflect previous discussion and principles?
The design workshop process
Principal Community Pathways –
How people have been involved So far 362 people have attended the 27
clinical and supporting systems workshops,
these have included: GPs, Local Authority
staff, Acute Trust staff, Community and
voluntary sector staff, CCG staff, NTW staff
and most importantly our service users and carers.
• Our Trust-wide Service User and Carer
Reference Group has been involved throughout
• We have presented our plans to various groups
including HealthNet and South Tyneside GP
Education Forum
• We’ve been ‘walking the wall’ with all of our
stakeholders and have so far run sessions for
over 800 people – with more to follow
The “Wall”
Benefits of PCP
Service Users and
Carers
CCGs Workforce
Partners
• Quicker, easier access
• Recovery focused,
collaborative care
• Enhanced packages of
care
• Alignment of care across
partners
• More efficient, safer
systems
• Integrated care
• No ‘bouncing’
• More time spent with service
users
• Clear roles and
responsibilities
• Increased job satisfaction
• Enhanced skills
• Improved communication
and information sharing
• Reduced duplication
Patient
Process step
Carers
Access Assessment Treatment Discharge
24 hour access Contact within 24hrs and offered choice of venue and appointment time
Self referrals No waiting lists Quicker re-engagement when needed
Able to make referrals Can ring for advice and support with or without a referral More informed, clearer plan
Within 7 days of referral receipt Given information to help prepare Text message or phone call reminder Greeted by front of house staff where clinic appointment needed Full baseline physical health check where required
Can be involved if appropriate Common sense confidentiality Assessments for carers
Text message or phone call reminders for appointments Patients receive treatment in line with NICE guidance Peer Support Workers and community workers to help with social issues Treatment and care in the most suitable environment Care plans developed collaboratively
Can be involved if appropriate in treatment planning and delivery Can request a review at anytime and help with decision making
Carer involved in discharge planning and have their own plan Re-engagement process available if needed
Discharge process is
considered from beginning of assessment helping to prepare for discharge Discharge plan includes how to ‘stay well’ and what steps they should take in the event of a relapse
Process step
GP & Partners
Referral Assessment Treatment Discharge
A single point of access for urgent or non urgent referrals using telephone, email, fax or letter 24/7
A copy of the assessment documentation within 48 hours
Where medication changes are required clear guidance and communication will be provided Clear and concise updates and action plans
A clear and concise discharge summary If relapse occurs a simple referral route back into services
Social Services
A single point of access for urgent or non urgent referrals
Co-ordinated discharge process involving all professionals
Part of review process as appropriate Joint treatment planning Holistic view of service users needs
Opportunity for joint assessments where indicated Shared information across organisations
Advice Line
Advice Line
Process step Referral Assessment Treatment Discharge
Community Staff
Inpatient Services
Specialist Services
Co-working
Link worker Specialist service provides a FAQ factsheet and online presentation to reduce repetitive requests for the same advice Earlier consultation for advice
Provision of scaffolding Estimate less usage as staff get skilled up in core services
Quick access to community services to enable transitions from other services
Continued involvement from the community team – in reach model, resulting in less need for inpatient therapies
Timely discharge from inpatients
Clearer plan and responsibilities
Quick referral and allocation of a worker Reduced need for inpatient beds
Discharge will involve all relevant health professionals and partners Positive attitude to risk management and safety planning Social needs addressed sooner
Based on workload not caseload Clear guidance on treatment that should be provided Will match skill set and train staff when needed Quick access to advice from specialist services
Preparation time booked in assessors diary Where possible the assessor will provide treatment Documentation reviewed so that assessment flows better
Streamlined approach to external and internal referrals Open referral system where we can ask more questions from the referrer / service user/ carer More responsive IT systems and less paperwork Access service will gather as much information as possible before the assessment