Introducing care coordination How care coordination keeps people out of hospital and living wellat home with support in the community

Case study

SummaryWe are introducing care coordination to improve health and care services locally and help people stay remain well at home.

Care coordination is an integrated system ensuring anyone referred to community services receives appropriate support from the most suitable professional when they need it.

To make services easier to navigate we have created a single phone number staffed by a team focussed soley on coordinating referrals and queries.

Care coordination aims to reduce pressure by keeping people out of hospital and reducing on the need for unplanned services by increasing support in the community and addressing problems before they escalate. We also work with social services and third sector organisations providing proactive support as needed.

90% of calls in Devon’s Single Point of Access are answered

in 30 seconds

IntroductionWhen we begin providing a new service we commit to improving it, in turn providing better value for the NHS and the public.Since 2006 we have delivered a wide range of community and primary care services. This usually involves taking on the work of many different services and organisations with disparate communications channels, technology and locations.

The logical solution is the coordination of these different parts of a service. However, we know this is just the first step to improving services and have adopted a model of ‘care coordination’ to improve services.

Care coordination is the management of an individual’s health and social care to support them to maintain their own health and wellbeing.

The aim is to enable them to stay well in their own homes by addressing medical and social problems before they escalate and so reduce the burden on unplanned and secondary care services.

We do this by establishing a care coordination centre - (CCC) integrating community health and social care support systems for those referred by GPs and often those who ask for support individually.

The challengeWhen commissioners look for a new provider to take on services in their area there are many problems that the bidder will need to demonstrate that it can resolve for them. Many community services are not integrated and have varying numbers of locations, contact points and phone numbersas well as hundreds of processes generating a variety of referral forms.

Sometimes services are run by a several providers and commissioners would prefer a single provider to bring services together and ensure they are equitable.

In addition there is often a lack of coordination between the NHS, local authority and third sector services. Invariably services face increasing demand with decreasing budgets. We are experienced at overcoming these challenges and can demonstrate a strong track record, specifically on how introducing a care coordination system overcomes these challenges.

The solutionIntroducing care coordination involves an iterative series of improvements.

We begin by developing a ‘Single Point of Access’ (SPA). A centralised team is pulled together to replace the separate, isolated community services’ administration teams.

In this first stage, local people and professionals can contact the team via a single telephone number or email address at any time for any aspect of their care.

Each level is developed with the ability to introduce the next level in mind – for example, IT infrastructure and clinical systems, online knowledgebase and directory of services, clinical triage, scheduling, telecare technology, bespoke website, rapid response team, out of hours system and online booking.

The standard offering is tailored to the specific location, service and commissioner requirements. At its most advanced, the CCC provides proactive population health management, wellbeing services and active care plans for highly vulnerable individuals.

I’m a leafletInformation guide

Virgin Care

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15faster at processingreferrals across allservices in Devon

44were reduced to 17 to process children with additional needs referrals

time taken for CAMHS to process referrals, a reduction from 9

3 days

were answered in one minute accross our sexual health services

90% of calls

in Devon’s SPA are answered in 30 seconds

95% of callsreduction in processing times for Speech andLanguage referrals

14day

days

A team of doctors, community matrons, nurses and trained care coordinators are based together at the CCC with strong links to partners within the health and social care system such as social workers, A&E teams and third sector partners like Age UK.

This ensures all parties needing to be involved in an individual’s care are alerted and action taken following contact with the CCC whether the need is a home visit from the rapid response team, advanced nurse practitioner or occupational therapist, providing remote monitoring, arranging appointments or even transferring the case to another agency.

Once someone is referred to the CCC the team works with them to develop a detailed care plan with input from all professionals involved in their care.

The differenceSince taking on services in April 2016 we have introduced the care coordination model in four areas – east Staffordshire, north Kent, west Lancashire and Devon. Each is at a different stage in the iterative rollout described above.

The CCC is central to the East Staffordshire Improving Lives Programme which focuses on helping people to stay healthier for longer and enabling those with long-term health conditions take more control over their own care.

The CCC takes 250 calls a day and is estimated to have prevented some 500 people from having to go to hospital during its first few months.

In September 2016 we began providing North Kent Adult Community Services and introduced the CCC.

It took more than 7,000 calls during December 2017, the highest monthly total so far. More than 98% of calls were answered within 30 seconds and calls to the team now take just four minutes, down from five minutes in 2016.

Devon Integrated Children’s Services celebrated the second anniversary of its advanced SPA in February 2018 and referrals have improved significantly as a result.

Average processing times have reduced from 27 days at the start of 2016 to 14.8 days throughout 2017.

In particular CAMHS referrals reduced from nine days to 2.5 days.

On average 94% of calls were answered within 30 seconds and more than 5% came directly from families reducing pressure on local GPs.

We began providing Adult Community Services and Urgent Care Services in west Lancashire in May 2017.

A SPA is currently being introduced and, the first part of a programme to introduce a full CCC. By 2020, West Lancashire Community Services will have a team of health professionals working and supporting local people to live independently for as long as possible and take control of their own health and wellbeing.

The SPA and CCC are supported by our integrated care records and the extensive use of mobile working technology which allows clinicians to access and update medical records securely wherever they are.

Case study correct as at time of printing June 2018

About Virgin CareVirgin Care operates more than 400 frontline health and social care services across England with a difference. We run a wide range services including adult and children’s community services as well as GP practices, walk-in centres and urgent care centres, all alongside sexual health, physiotherapy, dermatology and MSK services. From 2017, we started providing, for the first time, adult social care services to help promote the wellbeing of people to help them live independently for as long as possible with wellbeing and volunteering services available.

Virgin Care Limited and Virgin Care Services Limited are both rated ‘good’ by the CQC following inspections in 2017. Inspectors said that the organisation “could demonstrate through documentary evidence that following acquisition of services, they had managed to bring about a sustained, significant improvement to patient care”.

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