Wakefield’s Connecting Care Programme

Katie Roebuck, MCP Programme Manager

Overview

• Brief overview of Wakefield District• Connecting Care Hubs and evaluation• MCP Key Transformation Areas• Emergency and Urgent Care• Care Homes

Map of Wakefield

• To be added

Multispecialty community providers

moving specialist care out of hospitals into the community

Integrated primary and acute care systems

joining up GP, hospital, community and mental

health services

Acute care collaboration

local hospitals working together to enhance clinical

and financial viability

Enhanced health in care homes

offering older people better, joined up health, care and

rehabilitation services

Urgent and emergency care

new approaches to improve the coordination of services and

reduce pressure on A&E departments

Five new care models announced – Wakefield has 3/5

Programme Management & Governance

PMO

• Concluding the transition from West Wakefield and embedding new PMO arrangements within the Wakefield connecting Care team hosted by Wakefield CCG.

• PMO fully resourced and operational

Alliance Agreement & Governance

• 18 month Alliance Agreement to support work programmes of NMOC Board for “virtual” MCP arrangements is developed which has outcomes agreed by all partners across the system and is now signed by all partners.

• New governance structure in place, with the development of the New Models of Care Board & JODG Group.

Assurance Frameworks

• WMDC Public Health Team have developed at a project level detailed Physio, Pharmacy, Mental Health & Connecting Care frameworks, which align activity and finance more specific to cohorts.

• Care Home Assurance Framework and MCP Key Indicators framework have been developed.

Governance

MCP Vision

• “Creating person centred co-ordinated care” is the agreed Wakefield Vision which lies at the core of everything we strive to achieve working with our

partners in Connecting Care Health and the Social Care Partnership.

• The Multi-specialty Community Provider (MCP) model is about integration and removing historical barriers that

have prevented joined-up preventative patient care across primary, community, mental health, social care

and acute services.

MCP Outcomes framework

Connecting Care

To ensure our new model of care is delivering against an agreed series of indicators that support improved patient care across the health and social care system. Specific measures include:

Outcome 1: People can access information and advice that is clear, up to date and consistent

Outcome 2: Care and Support is responsive, timely and joined up

Outcome 3: Support is provided by caring, considerate people with right skills

Outcome 4: People live in safe and positive communities

Outcome 5: People are encouraged and supported to be healthy

Outcome 6: People are assured service and resources are efficient

Model of care- 8 key components for MCP Framework

“Through expanded community and primary care, proactive teamwork and new technology to deliver health and social care at scale to our residents of Wakefield and

our patients captured by our GP registered list”

Prevention Self CareCare

NavigationImproved

AccessSupport at

HomeAdmissions Avoidance

Early Supported Discharge

Connecting Care

Whole population prevention and

population health management

Urgent care needs –

integrated access and rapid response service

Ongoing care needs –

enhanced primary and

community care

Highest care needs –

coordinated community based and

inpatient care

Contract, commissioning

and funding

Flexible use of workforce and

estates

Building shared care records and

business intelligence

systems

Cultural and change

“What matters to me?”

Diagram: Connecting Care Hubs pathway Connecting Care Hubs Referral Pathways - Draft V:4 – 17.07.2017

GP

Ref

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C H

ubs

Wakefi

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On

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Bu

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Referrals to Social Care Direct (SCD) / MY Therapy &

Mid Yorks Single Point of Contact (SPOC)

GP Referrals direct to Connecting Care Hubs

Wakefield One

Triage Referral

pathways

Non Hub Response

SPECIFIC PERSON CONTACT /

OTHER SINGLE AGENCY REFERRAL (that is not based in the connecting care hubs).

Contact or referral passed to appropriate person /

agency to be actioned, then recorded & closed on

appropriate system

Non Hub Response

Bullenshaw / Waterton Connecting Care Hubs

Referrals received by Care Co-ordination Unit

Hub Referral Pathways

ROUTINE REFFERAL PATHWAY

Care Co-ordination Unit Actions:

Referral added to list for inputting / updating on

PIC and any other systems as appropriate

recording allocated team/person and

recommendations.

If ongoing local authority action needed, then

referral put on Care Director and allocated to

appropriate team.

INFORMATION / ADVICE /

SIGNPOSTING RESPONSE

Contact recorded & Closed on

appropriate system

Connecting Care Hub Response

URGENT REFFERAL PATHWAY

Care Co-ordination Unit Actions:

Verbally Make URT Team aware of referral.

Update/input PIC on other systems as

needed recording allocation and

recommendations.

If ongoing local authority action needed, then

referral put on Care Director and allocated to

appropriate team.

Routine Referrals

Urgent Referrals

TRIAGE BY HUB

DUTY MANAGERS

Recommended actions sent to Care Co-ordination

Unit to update PIC etc and allocate to appropriate

team as routine or

urgent referral

Referral received by allocated Connecting Care

Hub partner organisation / person and actioned.

PIC updated and lead worker assigned to co-

ordinate care plan if other services involve.

Referral received by allocated Connecting care

Hub partner organisation / person and actioned.

PIC updated and lead worker assigned to co-

ordinate care plan if other services involve.

Current Connecting Care Hub Partner Organisation Providing Hub Response

Social Care Direct / MY Therapy / Community Matrons / Age UK Wakefield / Wakefield Carers / Connecting Care Pharmacy / WDH / Mental Health Navigators

Connecting Care Hubs Communication to GP

This is Connecting Care…

(Link to Connecting Care overview)

Connecting Care Hubs: LA- WMDC Funding commitment to model

“ASC/ BCF Funding & Estates”

• Additional care co-ordination and social work staff, recruitedto multi-disciplinary team to enable 7 day locality working

£1.1 million

• Additional care co-ordination and social work capacity for Hub/ Hospital Interface to facilitate new “Discharge to Assess” arrangements

£260k

• 1/3 contribution to establishment of new unit of co-ordination support officers

£140k *WMDC contribution

• Estates and accommodation developments to provide modern facilities to deliver new ways of integrated working

£2.2 millionFunded from WMDC capital reserves

MCP key transformation areas to be delivered in 2017/18

Connecting Care

Resources have been secured from NHS England to support Wakefield District to roll out some key transformation projects during 2017/18. Eight of these transformation projects are integral to primary care and community care development and are outlined in Wakefield’s Delivering the General Practice Forward View The Wakefield 2020 General Practice Plan. These include:

• Integrated Nursing Teams• Primary Care Mental Health• Late Visiting Service• Developing a Wakefield Training Academy for

Primary Care• Increased access to pharmacy• Physio first/line

Progress to dateWakefield commissioners across system have over the last 2 years worked together to ensure that Wakefield has plans in place to fund the interventions that NHSE has funded across our system that have had impact. This is a summary of the progress to date:MCP VanguardThrough a series of commissioning reviews in WCCG and WMDC funding solutions are in place for the following areas of the model of care from April 2018:• Discharge to Assess (funded through WMDC iBCF resources that are available 3

years)• Late Visiting service (funded through decommissioning a historic LES for general

practice to fund this model across District from April 2018)• Physio in General Practice (funded through the community Physio funding

envelope within CCG from April 2018)• Pharmacy in General Practice- this detail still being worked through with

practices but likely to be a combination of top slice of prescribing budget and part contribution from general practices – CCG will confirm in q3 assurance meeting

Progress to dateWakefield commissioners across system have over the last 2 years worked together to ensure that Wakefield has plans in place to fund the interventions that NHSE has funded across our system that have had impact. This is a summary of the progress to date:MCP VanguardThrough a series of commissioning reviews in WCCG and WMDC funding solutions are in place for the following areas of the model of care from April 2018:• Care Navigation training and support for Wakefield practices- to be confirmed in

q3 assurance meeting but discussions with Conexus underway and this is likely to be provided from Conexus with no cost to Wakefield system from April 2018

• GP OOH access model (GP Care Wakefield)- funding is available from NHSE for this and NHSE NMOC team stopped funding this in year 2

• Carers Support and Age UK support to model of care- funding is available from the reduction of 78 to 26 inpatient beds in MYHT – this has been removed from MYHT community contract and transacted

Evaluation Headlines – MCP Key Indicators

Over 65 cohort established as those most likely to benefit from interventions

Activity compared to 2016/17 baseline (April – August 2017):

• 4.5% reduction in emergency admissions

• 2.4% reduction in ambulance conveyances

• 3.3% increase in A&E attendances

• 4.3% increase in emergency bed days

Evaluation Headline - Pharmacy

Savings generated May – Sept = £351,459.

Average of £258 saved per pharmacist intervention (1,360 interventions).

31% of patients had their treatment simplified.

17% of patients had a redundant item removed.

Evaluation Headline - Physio

Physio Line (Apr – Sept vs 2016/17 baseline)

– 41% reduction in first appointments to community physiotherapy

– 34% reduction in follow up appointments

Physio First

– 13% increase in first appointments

– 3% reduction in follow up appointments

Rest of the District

– 3% increase in first appointments in community physiotherapy service

– 7% reduction in follow up appointments

NHSE National Enhanced health in Care Homes Framework

Wakefield Model

27 care homes as part of the vanguard (mainly residential and nursing homes over 65`s)

Working with 27 GP practices (38 practices in Wakefield)

This equates to 1,594 active beds (total bed base for Wakefield 2435 active beds)

Plus 6 extra care facilities working in partnership with Wakefield District Housing and Wakefield Council

Evaluation Headlines – Care Homes

Phase one and two combined position YTD vs 2016/17 baseline

Emergency admissions: +1%

A&E attendances: +1%

Ambulance calls: +7%

Bed days: +0%

Phase one performing ahead of target in all except ambulance calls, Phase two not hitting target.

Unified primary and urgent care

NHS 111/999

GP Practices

Community pharmacy

Pharmacy in general practice

Enhanced services

Social prescribing

Information and advice

Assessment

Safeguarding

Homecare

Residential and nursing care

Connecting Care Hubs

Single point of contact

Social care

Voluntary sector navigators

GPs and consultantsMedical outreach

Integrated community health

care teams

Rapid response Late Visiting Service Ambulatory Emergency Care

Social Care

Urgent Care Treatment centre

Walk in centre

Primary care streaming

A & E

Hospital to home

Frailty units

Discharge

Outpatients

Unified secondary care response

Personal integrated file

Real time situational analysisGP Care (Extended access)

Clinical advice booking service

West hubFace to

face

Trinity Medical centre

East hubFace to

face

Same day access for routine care

Physiofirst/Physioline

Care Navigation

Appropriate referral of patients back into primary care via GP located within A & E

Integrated pathways to all services

WY Urgent Care OOH

Direct stroke service

Specialist services

Diagnostic access

Planned service provision

What have been the challenges?

• Multiple Providers each operating in their own silos– Separate teams

– Differing cultures / value systems

– Inclusion / exclusion criteria, Referral forms

– Poor information sharing, lack of IT and IS integration

– Lack of trust and mutual understanding

– Differing KPIs and targets

– Tendency to shunt problems around

– Gaps and overlaps

– Reactive not proactive

– Slow to respond

– Organisational hierarchies

– Lack of communications technology

– Focus on caseload and no situational awareness

– Struggling workforce

• Lacking clinical leadership on the ground

What we learned

- The source of most of the frustrations and anxiety have been the result of different messages and language. Getting the right message across to clinicians needs careful thought and planning.

- Things don’t always work – pharmacy first very low uptake.

- It takes time to build relationships and trust

- Without a properly positioned PMO or ‘engine’ room for delivery, an organisation will struggle to ensure action plans are delivered in line with expectations and at the pace required.

- Business As Usual (BAU) can take too much of the week up – capacity needs to be created in order to work more effectively on addressing the financial challenge.

Thank you