Commissioning for Outcomes7-day services across the community

Paul MaubachChief Accountable Officer

Dudley CCG

Dudley CCG: context

CCG registered population = 312,000 48 practices 10 single handed practices Mixture of wards including some in the lowest

20% for most deprived across the country and some in the top 20% of most affluent.

Our starting point

Population-based healthcare

Our CCG is a population-based organisation of c.310,000 registered members

A substantial proportion of the national outcome measures are population based:

• NHS Outcomes Framework• Adult Social Care Outcomes Framework• Public Health Outcomes Framework• CCG Outcomes Indicator Set

Deaths by Day in Dudley - 2012

Day Mortality (Ave deaths per day)

Sunday 7.5

Monday 7.8

Tuesday 7.6

Wednesday 7.6

Thursday 8.1

Friday 8.4

Saturday 7.8

Local Dudley Service Provider

Need not Convenience

‘Our caring, compassionate and highly experienced staff are available 24 hours a

day where you can be guaranteed of a personal service from the first call. If you

can't get to us don't worry, we will be happy to visit you in the comfort of your

own home’

A Mutualist Approach

Shared Ownership Each citizen is a registered member

Shared Responsibility Co-production with the individual Services working together

Shared Benefits Personalised and population outcomes

7 day services: variation in delivery

Mon Tue Wed Thu Fri Sat Sun

-15

-10

-5

0

5

10

15

20

Average Net flow of Patients (admissions vs discharges)

Post weekend peaks in admissions Postponement of discharges due to absence of

support services – therapy, pharmacy etc.. Unnecessary admissions due to absence of

more appropriate primary and community health services

Inconsistency of patient experience and response, 7 days per week

7 Day Response To Avoid…..

Mapping services – moving some to 7 days Introducing new services – rapid response Improving infrastructure – standard, mobile IT Developing community standards System alignment - to share responsibility Organisational Development – whole system New innovation – patient-led outcomes Commissioning for outcomes

7 day services – Early adopter

7 day services – connection to Integration & Better Care Fund

7 day services

Community Rapid Response Team

OD: Leadership programme

Prevention agenda and tele-health

Risk stratification

Single point of access

Dudley Care Home programme

Integrated teams

Community Mental Health Teams: adults

and older people

Palliative care teamHeart failure-

joint pathway with acute

OT

Physio

Care home nurse

practitioners

Stroke

NeurologySocial

service teams

SLT

Current 7 day working

From July 2014

Potential to move to 7 days in 2014

MH Crisis Resolution

Community Rapid Response Team

Tele-care services

Dementia Gateways

District Nurses

Current 7 day

working

Intermediate Care

Community Respiratory Team

Virtual ward (Case Managers)

Care home provision

Evidence base:- 19,500+ over 65 arrived at ED 14,500 admissions over 65 10,000+ over 75 6,500 admitted for 2 days or less 85% arrived by ambulance

Community Rapid Response Team

Community Rapid Response Team for Older People with Frailty

Integrated with Care Home Nurse Practitioners and Social Care Assistants

PATIENTS

WMAS

NHS 111

GP Out of Hours Community Nursing Teams

Assessment by ANP or Care Home Nurse PractitionerWithin one hour

Step down to Locality Integrated Teams

Single Point of Access forAdvanced Nurse

PractitionerBased at WMAS

Admit to

EAU

- Initiate treatment → - Initiate care package → up to 7 days (then review) - Initiate care plan

Over 2,200 residents in nursing and residential homes registered with a Dudley GP

High number of urgent care admissions Dudley Care Home LES operates to provide

proactive care and initiate advanced care plans. Team of 6 care home nurse practitioners to

double in size to be integrated with rapid response team and become a 7 day service.

Dudley Care Home Programme

Imperative that community practitioners have access to pertinent information and particularly for a 7 day service when practices are closed.

All practices now on EMIS web Piloting tablet using ‘Inchware’ technology to

access medical information remotely including the ANPs

Improving Infrastructure: Mobile IT

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4.00

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ACG Probability of Future High Cost

Actual Avg no FHS

Actual Avg no OPAs

Actual Avg no AE Attendences

Identification of risk using ACG tool MDT Care Planning Care gap

Improving Infrastructure: Risk Stratification

1. Patient experience2. Integrated team review3. Information and communication4. Diagnostics 5. Speed of access and assessment in the community6. Mental Health7. Quality Improvement8. Palliative and End of Life

Community Standards

Community nursing and therapy services have a single point of access

Social services have a single point of access Both in the same building! Moving to joining together and include mental

health

Aligning Services: Single point of access

Practice integrated teams GP, pharmacists, community nurses,

named social and mental heath workers. To review risk stratification tools; agree a Care Coordinator for complex cases; take shared responsibility for outcomes

Locality MDT teams GP Leadership posts in each locality.

Remit of reviewing collective outcomes of all teams in their locality and ensuring pathways to locality to borough wide services function effectively

Aligning Services: Integration Model

Dudley Leadership Group (System resilience group) Vertical authorisation for the work

Change Project Team Early adopters for our Analytical Network Change Process Recognises importance of shared responsibility and networked leadership

Information Sharing and Development Days: New Working Practices to Improve delivery All front-line staff go through the same induction and development programme

Facilitated Multi-Professional Team Working: To deliver networked care for their population Planning how to work together, rather than have imposed top-down solutions

OD programme

Person

GP Practice

Community

CCG / specialist (hospital ?)

teams

Registered Member

Based in a Locality

Part of a System

Aligned, Networked Population Health and Wellbeing Services

Commissioning for outcomes

From a Representative approach: Patient perspectives and involvement is standard

To: Fully Participative approach: Development of systematic tool (PSIAMS) to record the patient

experience of care Enables patient to establish their own outcome goals with the services

and chart their progress against them Includes health and wellbeing as well as social impact outcomes Piloting with VCSE organisations

being upskilled & changing their practices. Enables market entry for smaller organisations

Gives us outcome data for every person receiving care

Patient-led outcomes

Population outcomes

With networked teams operating on the same population basis we can now implement performance management and incentives for population-based outcomes

Practice networks link collectively to the system network Developing shared outcomes across providers Both vertically and horizontally

Introducing first set of incentives for 15/16 contracts Join our working group!

A Mutualist Approach

Shared Ownership Each citizen is a registered member

Shared Responsibility Co-production with the individual Services working together

Shared Benefits Personalised and population outcomes