all together better sunderland - necs · 2019. 2. 20. · sunderland care model communi t y r esour...

All Together Better

Sunderland A Vanguard Multi-Speciality Community

Provider; The Importance of Being ODD

Jon Quine & Tracey Watson

Organisational Design & Development

@JonQuine | @Traceywnhs | @ATBSunderland


Highest Needs Ongoing Care Urgent Care Needs Whole Population


Primary Care

Community Care

Mental Health

Social Care

CVS Acute Services ED

Sunderland Care Model Community resources and Resilience:

Patients who will benefit from better coordinated care and enhanced long-

term condition management, including

self-management

Enhancing Primary Care:

High risk patients who will benefit from multi-disciplinary

person-centred coordinated care. Comprehensive care

plans including risk management planning

Elderly Frail / High Risk Population: City-wide multi-agency Resource Hub:

Risk Stratification

2% - 5%5% - 10%

North LocalityPractices

West Locality Practices

East Locality Practices

Washington Locality

Practices

Coalfields Locality

Practices

Com

mun

ity R

esou

rces

and

Res

ilien

ce:

Robust Health and Wellbeing Strategies – Health Promotion; Self- Management; Leisure;

Recreation; Meaningful Occupation; Housing, including extra care; Strong Voluntary Sector;

Faith organisations

North Integrated Teams

West Integrated Teams

East Integrated Teams

Washington Integrated Teams

Coalfields Integrated Teams

Urgent Care Centres

Recovery at Home Service

Community Integrated Recovery at Home

Telecare and Community Equipment

Therapies

24 hour Single Point of Access – the Intermediate

Care Hub

GP Out of HoursCo-located with Recovery

at Home Service111 / 999Urgent Response; Triage;

Navigation to appropriate response

Providing alternative to hospital admission. Supporting individuals to recover from illness or crisis and to regain independence in their own home or as close to

home as possible. Facilitating discharge for individuals who have to be

admitted, ensuring their stay is no longer than necessary. Preventing unnecessary admission into long term

residential or nursing care. Reducing the requirement for an on-going social care

package of support.

Community Connectors

Community Connectors

Self Management

Self Management

Ambu

lato

ry

Emer

genc

y Ca

re HHospital


Self-care & Self-management – Whole

Population

• Communication and engagement

• Workforce Development

• Identification and engagement of local community and voluntary

organisations

• The use of the Patient Activation Measure (PAM)

• Technology and Telehealth to support self-care and self-management

• Supporting carers and family networks


Recovery at Home – Urgent Care

• 24/7 Single Point of Access

• Collaboration of NHS community and Sunderland Care &

Support services

• Intermediate and Urgent Care Nurses and Therapists, with GP

pilot

• Reablement staff proving short-term home care package

• Short-stay bed-based services

• Telecare


Enhanced Primary Care – Ongoing Care

• GP Federation of 42 / 50 practices – Sunderland GP Alliance

• Releasing capacity, increasing capability

Alignment of practices to care homes

Locality based ECG clinic

Map of Medicine

Post-discharge information

Workflow optimisation

Locality insulin initiation hubs


Community Integrated Teams – Highest Needs

• 5 Localities based in Primary Care Centres

• District Nurses, Community Matrons & Care Home Nurses

• Social Workers and Assessment and Review Officers

• Age UK Sunderland Living Well Link Workers

• Sunderland Carers Centre Locality Leads

• GP Alliance MDT Coordinators

• Serve defined practice populations thereby aligning with Primary Care


Multi-Disciplinary Teams – Highest Needs

• Contractual arrangement between CCG and SGPA

• Binds providers into meeting contract requirements

• Weekly MDT practice > 5000, fortnightly < 5000

• 2% practice list, and all care home patients (3% of

population)

• EHCP and MAP

• Risk Stratification

• Q Admissions

• Frequent flyers

• High cost patients

• Professional judgement

• Social Care


Enablers

• Digital Solutions

• Organisational Development & Workforce

• Communications & Engagement

• Patient, Public & Carer Engagement

• Business Intelligence

• Evaluation

• Estates

• Sharing & Learning



MCP Exec

Implementation & Assurance Group

Design & Planning Group

West North East Coal Wash

System Architecture


Commissioner Governing Bodies

Care Model Assurance Group

Provider Governing Bodies

MCP Exec

Operational and Enabling Groups

Joint Strategic Board

Joint Senior Leadership Team


System Leaders and Pirates

4 Domains of Developing System Leadership

• Individual effectiveness of the leader –Myers-Briggs Type Indicator (MBTI) personality preference, 360 degree feedback, coaching balance wheels and co-active person centred coaching.

• Relationships and connectivity – coaching to explore the health of relationships and connections across the system with specific work on strengthening relationships that add value to the service user.

• Innovation and improvement – explore the skills and capacity of the staff to problem solve, service improve, and sign post to developments already available within the system.

• Learning and capacity building - coaching around how new ideas, research and skills could be diffused and shared within and between the 5 locality teams across the city.


‘Breaking the Hourglass’

Strategic & Senior Leaders

Operational Managers

Team Leaders and Workforce


Challenges Identified

• Cultural Differences – perceived different value worth of teams and services • Operating Cultures - permission to act and collective leadership, to a hierarchical

autocratic style • Imposter Syndrome -people often felt uncomfortable in not having all the solutions,

and not knowing the full system picture • System Leader takes extra effort - takes extra discretional effort over and above the

pull of their day job



Project Cells


Creating Networks

Themes from Sunderland GP & Care Home Alignment Workflow Optimisation Ambulatory ECG in locality hubs Insulin initiation in locality hubs GP locum bank Map of Medicine Community Integrated Teams MDTs and Care Planning Risk Stratification & Caseload Finding Care Coordination Locality Networks Mental Health Integration

Business Intelligence Recovery at Home Patient Activation Measures (Self Care) Social Prescribing (Self Care) MCP Development Information Sharing EPaCCS Telehealth Staff engagement Public engagement Branding OD & Integration

www.atbsunderland.org.uk

@ATBSunderland

@JonQuine

@Traceywnhs

[email protected]

http://www.atbsunderland.org.uk/

mailto:[email protected]

all together better sunderland - necs · 2019. 2. 20. · sunderland care model communi t y r esour...

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