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Principia Showcase 2017 – Elective Care Workshop
Dr Matt Jelpke
Steve Murdock
Sister Donna Rowe
Innovate - Integrating acute and community care
Initiatives include:
• F12 Pathfinder – clinical guidelines, pathways, standardised referral forms, clinical templates
• Clinical Variation methods – Peer-to-peer review, advice and guidance
• Clinical Assessment Service (CAS) and development of standardised referral processes – Referral management
• Triage / Pre-assessment – e.g. within Gastroenterology pathway
• Elective care community services – Gynaecology, Dermatology, Trauma and Orthopaedics, Ophthalmology (ENT and Respiratory in development)
• Secondary care outpatients appointments – patients who do get referred to secondary care arrive fully worked up (e.g. including completed minimum data sets); greater integration between GPs, consultants, and community services; fewer follow ups
• Community services clinic coordinator – post dedicated to managing the range of community clinics operating in Rushcliffe
Elective First Outpatient Attendances – • Over 17/18 Plan by 8.5% or 63 first attendances Emergency Admissions – • Over 17/18 Plan by 19.7% or 61 admissions Advice and Guidance – • Achieving 17/18 plan at 33%
Innovate – Reducing variation between practices
Innovate -
GP F12 Pathfinder, peer-to-peer review, completed minimum data set
Centralised Secretarial Function Standardised approach using agreed referral templates
Referral Management Service (CAS) Mandating correct referral templates and co-ordinating pathways
Triage / Pre-assessment
Ordering of tests and diagnostics Gynaecology, T&O,
Respiratory, Gastroenterology, Fracture
Liaison Service
Community service Gynaecology, Dermatology,
ENT, T&O, Respiratory, Ophthalmology, Fracture
Liaison Service
Secondary Care This processes will ensure only those patients that require secondary care will be referred with
some/all of the following:
• Standardised referral template agreed with secondary care clinicians • Completed minimum data set • Additional tests/diagnostics completed via pre-assessment • Appropriate recommendations for direct listing for procedures (where relevant/agreed) • Indication of the correct clinic/consultant/specialty
Back to GP with advice
Gynaecology, Dermatology, ENT, T&O, Respiratory,
Ophthalmology, Fracture Liaison Service
Elective Pathway
Evaluate – Measuring impact
Total completed referrals
552
Booked to clinic
293 (53%) GP management
60 (11%) Diagnostics ordered
199 (36%)
Booked to clinic
87 (16%) GP management
112 (20%)
Consultant Triage
Consultant Triage
Booked to clinic 380 (69%)
GP management 172 (31%)
Total
Nottinghamshire Digestive Diseases
Interface – “The Gastro Pathway”
Evaluate – Measuring impact
Evaluate – Measuring savings
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2016-17 £20,678 £40,817 £64,032 £87,838 £110,476 £131,928 £149,451 £170,334 £185,947 £209,209 £221,308 £238,097
2017-18 £11,513 £25,766 £42,169 £61,302 £78,287
£11,513 £25,766
£42,169 £61,302
£78,287
£0
£50,000
£100,000
£150,000
£200,000
£250,000
£300,000
Cu
mu
lati
ve C
ost
OP 1st GP Gastroenterology - Cost Rushcliffe CCG
2016-17 2017-18
Rushcliffe CCG: • Month 5 =
£32,189 saving • Full year
estimate = £71,430 saving
Greater Nottingham potential: • £506,480 per
year saving
Evaluate – Patient experience
Example – Community Gynae feedback: Example – FLS feedback:
0 20 40 60 80 100 120
The personal manner of the individualwho contacted you to arrange your
appointment
The information you were given beforeyour appointment
The availability of appointments
The waiting time from seeing your GP toyour appointment
The convenience of the clinic location
The standard of the facilities at the clinic
The waiting time at the clinic
Your overall experience
DNA
Excellent
Good
Average
Poor
0102030405060708090
100
Poor Average Good Excellent DNA
1. The personal mannerof the individuals youspoke to regarding yourappointment
2. The waiting time fromthe point of referral toyour appointment
3. Ease in arrangingappointments
0
20
40
60
80
100
120
Poor Average Good Excellent DNA
4. Did you feel that yourprivacy and dignity wasmaintained at all times
5. Did you feel able todiscuss your condition andtreatment (if applicable)during your appointment?
6. Did you fully understandany explanations about thelikely result of yourtreatment if required?
7. Overall how satisfied areyou with the service youreceived?
Replicate – Spread
Geographic: • The community clinic model as developed in Rushcliffe is poised to spread:
‒ Rollout of Gastro pathway to Greater Nottingham CCGs via Rushcliffe CAS in plan for Q4 2017/18
‒ Greater Nottingham CCGs currently reviewing the community Gynae service for implementation in all CCGs
‒ Community ENT clinic model under development – NHS England has shown interest in the model and how it can be spread to other CCGs
• Fracture Liaison Service has spread across South Nottinghamshire as of Dec 2016 • The F12 Pathfinder is in use in two thirds of GP practices across Greater
Nottinghamshire • Clinical Assessment Service (CAS) is being developed and considered how can be
spread across Greater Nottinghamshire. Laterally within Rushcliffe’s Elective Care: • Spreading pre-assessment/triage model to other specialties once proof of concept is
tested in Gastroenterology.
• What is in it?
• Pathways and referral guidance (national and local)
• Minimum Data Sets
• Templates and Forms
• Tools and helpers (protocols)
• Patient Information
• Useful information (PLCV, contacts etc.)
• What are its objectives?
• Remind & inform busy clinicians of the correct, up to date pathways and templates available for patients
• Signposting information for nurses and GP receptionists
• Reduce clinical variation, standardise data input and output and make everyday tasks more efficient and easy
• Who is it for?
• Everyone! It will benefit all primary and secondary care staff and patients.
• What is it?
• A series of templates built directly into the primary care clinical systems to aid navigation, path-finding & clinical guidance, data entry and referrals for the south and city CCGs
Innovate – F12 Pathfinder
F12 Pathfinder
F12 Pathfinder
F12 Pathfinder
F12 Pathfinder
Evaluate/Replicate – Data and spread
0
200
400
600
800
1000
1200
1400
May June July August September October
Nu
mb
er
of
use
s
Number of coded uses of F12 pathfinder per CCG per month
Rushcliffe (04N)
City (04K)
West (04M)
NNE (04L)
11
20 3
10
1
34 9
10
0%
20%
40%
60%
80%
100%
Rushcliffe(04N)
City (04K) West (04M) NNE (04L)
Number of practice visits from F12 team per CCG
left toVisit
Visited
11
23 7
19
1
31 5
1
0%
20%
40%
60%
80%
100%
Rushcliffe (04N) City (04K) West (04M) NNE (04L)
Number of practices with F12 access per CCG
F12 access Remaining practices
Innovate – Rushcliffe’s Fracture Liaison Service
The vision: to optimise the identification, treatment, and systematic management of those who present with an increased risk of fragility fracture, including vertebral fractures Global evidence demonstrates FLS improves care quality & reduces costs: “.. efficient, preventative model for fracture management” (Mitchell, 2014) Osteoporosis is “a national healthcare priority” (DoH, 2014): • 3 million people affected in the UK (1 in 2 females and 1 in 5 males over 70 years old) • 560k fragility fractures annually:
• 50% of those with fragility fractures require social care • 25% of those sustaining a hip fracture die within 12 months (NICE, 2009)
By “capturing the fracture,” we help prevent 23% of secondary fractures (NOS, 2015) which occur within 12 months of an initial fracture, which results in: • Reduced mortality • Improved quality of life and patient outcomes • Optimised health and social care spend
Fracture Liaison Service
“5IQ” (NOS, 2015):
IDENTIFY new or previous low-trauma fractures, or those at an
elevated risk
INVESTIGATE: FRAX / DEXA / VFA, blood tests, x-ray, PMH / FHx, BH consultation , falls hx: determine
modifiable risks & optimise intervention(s).
INFORM: GP / patient / AHP : credible advice re falls, determining
fracture risk, optimise treatment, lifestyle advice, management
• INTERVENE: optimise care
planning, drug treatment,/analgesia and promote non-pharmacological interventions to reduce primary/ secondary fracture risk
• INTEGRATE: cohesive shared
care between services for optimal management to reduce/avoid fracture risk
QUALITY ASSURANCE: data collection, audit, QA tools (including patient survey)
database management and team CPD opportunities
Fracture Liaison Service – Our current model: an overview
Patient with new/existing
fracture(s) or at an increased risk
of fracture
Acute referral: ED list / GP clinic referrals / DEXA
referrals
Primary care referral:
searches, referrals, self-
referrers
Community FLS
Investigations
To assess bone health +/-a
falls risk;
assessment/medical review
where appropriate
Patient education – an
enabler
Patients engage with their
condition, facilitating self- management
Interventions
To improve bone health,
knowledge &
understanding; referrals to specialist services.
Integration
Shared care & systematic management
Fracture Liaison Service in Notts – “Reactive and proactive”
Systematic identification:
• Patients with new or historic fragility fractures
• 4 and 12 month follow-ups (improved compliance)
• Establishment and maintenance of an FLS database/DEXA recall system
IV Zoledronate:
• As first line treatment : 100% concordance, minor s/e & approx. 50% reduction in hip fracture/re-fracture in 3-5 years
Other benefits:
• High profile community presence
• Support & Guidance For H/C professionals & patients: a ‘Point of Reference’
• Cohesive pathway between FLS and AHPs/Therapy/Falls Services
Audit:
• Falls and Fragility Fracture Audit Programme (RCP)
• Measures against NOS Clinical Standards (2015) / CCG KPIs
Evaluate – FLS data so far
IV Zolendronate infusions: • Annual target: 32 infusions within the community • 2016/17: 153 infusions • 2017/18: 79 infusions so far (as of month 6)
Identifying patients:
• 674 patients identified as appropriate for the service in 2016/17 (the National Osteoporosis society predicted 593 patients in Rushcliffe)
• This highlights the service’s robust risk stratification and identification processes and the relationships established with referral sources
Evaluate – FLS data so far
Replicate – FLS expansion and spread
Expansion and evolution of the service: • The service was primarily commissioned to intervene at first fracture. • Established links between primary and secondary care and investment from Rushcliffe
CCG in 17/18 has allowed for: • Expansion to deliver IV Zolendronate to a wider cohort of patients, including
patients with risk factors for fragility fractures • Facilitation of discharges from secondary care for cohort of patients with
established osteoporosis who have been attending regularly for IV Zolendronate – these patients are now discharged into primary care for follow up via FLS
• All osteoporosis referrals to the Clinical Assessment Service are directed to the FLS – initial advice provided by the community Clinical Nurse Specialist Lead , who can escalate to hospital specialist nursing and consultant where appropriate
• Specialised template on SystmOne for all queries/referrals for ‘osteoporosis’
Spread within Nottinghamshire: • FLS launched in Nottingham North and East and Nottingham West CCGs on 1
December 2016