2

CHEADLE & BRAMHALL NEIGHBOURHOOD

ENGAGEMENT WORKSHOP SESSION THREE

18 AUGUST 2015

3

Purpose• To design an approach for the identification of patients requiring complex case

management and a pathway for the delivery of multi-disciplinary group management; in Bramhall & Cheadle Hulme and Cheadle, Gatley & Heald Green neighbourhoods.

Outcomes• Reviewed the outputs from session two together• An understanding of the lessons learnt from the Marple and Werneth multi-

disciplinary complex case management programme• Designed a pathway for the delivery of multi-disciplinary group management in

Bramhall & Cheadle Hulme and Cheadle, Gatley & Heald Green neighbourhoods• Design an approach for identification of patients needing complex case

management in Bramhall & Cheadle Hulme and Cheadle, Gatley & Heald Green neighbourhoods.

Development phases

Core teamGPs , DNs, SWs

Core teamPlus 3rd sector

Core teamPlus 3rd sectorMental Health

Core team Plus 3rd sector, Mental Health, Therapy, Intermediate tier

Full new Out of hospital service with prevention, planned and urgent links

Plan Do

Study Act

Plan Do

Study Act

Plan Do

Study Act

Plan Do

Study Act

Plan Do

Study Act

HabitsBehaviours, skills and knowledge needed.

Culture development – the way we think and behave around

here

ProcessesMechanics,

meetings, protocols etc. How decisions

get made, risk, assurance and performance frameworks

StructuresWho is responsible

for what (accountability) and

distribution of functions/tasks (responsibility)

Leadership culture which supports and motivates our staff to provide the best care to our patients

COMPLEX CASE FINDING AND MANAGEMENT:

Learning from Marple and Werneth

What do we mean by complex?

In Marple and Werneth:

Any person who is over the age of 18 and is a Stockport resident, a person with a long term condition and one or more of the following will be identified as having complex needs:• The person will have been identified as benefiting from a multi-agency approach to

support their care.• The person has been identified as being at high risk of readmission to hospital • The person’s condition, social band or functionality has deteriorated or become

unstable

However:• Many people with multiple conditions are managing well with the support they have• Often social circumstances are what makes a case complex – housing issues, debt,

isolation, family dynamics

Require complex continuous care

‘Layered’ issues

Frequently require services from

different practitionersMultiple chronic

conditions

Ability to perform basic daily functions affected

Frequent hospitalisations

SHARED AIM

• To wrap care around the needs of people with multiple layers of complex health and social care needs, and their carers.

• To develop personalised, holistic care and support plans with people to ensure they can live the most independent life possible and stay in the home of their choice.– To anticipate and plan for escalation or deterioration.– To manage their medical illness and social care needs.– To promote self care/management– To agree the plan, and thus its implementation, with the person in

the context of their own personal goals

CASE FINDING

• Predictive modelling– Patients at Risk of Readmission - Combined PARR

• Some appropriate cases, but many that are managing well or appropriately• Regular updates work best as list changes quickly• Historical data crisis often over by time flag.

– Multiple comorbidity • Some appropriate cases, but many that are managing well or appropriately• Does not change in the same was as PARR

– Frailty

• Other methods– Personal recommendation

• from hospital• from partners – NWAS, Housing, Third sector, Private Providers• People making contact at any point in the system that would benefit from other

involvement (routine or unplanned face to face, HWB check etc.)

CASE SHARING

• Multi-disciplinary Neighbourhood Service case sharing– Regular meetings – at first– Emails / Telephone calls– By the kettle

• Case coordinator• Consent• Everybody’s responsibility to participate by finding and sharing cases• Rapid discussion and assessment of need and support• Share pertinent information to avoid duplication• Understand colleague’s roles, capacity, and skills• Trust one another’s judgement and abilities• Available to act on what is being asked

“I saw Mrs X today... I think she needs support

with …..”

“Could you give Mr Y a call about ……”

“Did you know Mrs Z went into hospital last night…

CASE MANAGEMENT

• Holistic assessment• Case coordination• Personalised care and support plans that plan for

deterioration / escalation• Continuous information flows within neighbourhood

service, and access to colleague’s support and participation

• Access to wider support and advice– Pathways for escalation and deterioration that support people in

the neighbourhood, and rapid de-escalation to draw people back to neighbourhood support as soon as possible

– Locality Practitioner Group

• Clarity around who owns clinical risk

LOCALITY PRACTITIONER GROUP

• Meeting needs that cannot be met though neighbourhood service support or intervention, by working with partners outside neighbourhood service

• Joint problem-solving and positively managing risk • Participation from professionals that can supply information and act on it

– GP Practice staff– Nurse Social worker– Allied health professionals Third sector– Pharmacist Mental health– Housing Etc….

• Participation can be virtual and case-related – tel/ video conference• Preparation by case coordinator and participators in advance• Discharge back to mainstream delivery when appropriate, and re-

escalate if required.

GP ROLES IN COMPLEX CARE

• Identification of people with complex need (not just GP)

• Validation of the data from risk stratification• Medical element of care planning• Medical management• Maintaining medical responsibility whist person is in

normal place of residence• Clinical leadership to the multi-disciplinary meetings• Using the model of care as defined

KEY QUESTIONS

• How will you identify appropriate cases?• How will you ensure that the most appropriate person

deals with the case?• How will you prioritise the most appropriate cases?• How will you access specialist and borough-wide

services when you need them?