1. Principal Community Pathways h Sunderland & South Tyneside

2. Principal Community Pathways
A programme to design and implement new, evidence-based community pathways for adults and older people.
Our ambition is high and is matched by the expectations of service users and carers. The new pathways will:
Significantly improve quality for the patient
Double current productive time of community services by redesigning current systems
Enhance the skills of our workforce
Improve ways of working and interfaces with partners
Reduce reliance on inpatient beds and enable cost savings
This is not achievable in isolation and to be successful we need it to be part of integrated work with partners

3. Principal Community Pathways – Timeline
Jan 14
Design
Test
Implement
Apr 14
July 14
Oct 14
Jan 15
Pre-engagement
Apr 15
Tranche 2 – Northumberland & North Tyneside
Tranche 3 – Newcastle & Gateshead
Tranche 1 – Sunderland & South Tyneside

4. What will be different? Current Experience Our Commitment
There are lots of confusing ways to access services
Most non urgent services operate Monday to Friday 9 – 5, and there are waiting lists
Treatment episodes cannot always be linked to an outcome or a nice guidance recommended treatment, staff often have to refer to others for treatment
Patients can bounce around the system
Staff time is taken up with typing, driving and admin
Patients stay in services for a long time due to lack of joined up working and support to help them recover
Patients don’t want to be discharged because it’s hard to get back into services
Our Commitment
There will be a single point of access for all referrals
Most non urgent services will work from 8am – 8pm, and waiting lists will be minimal
Treatment packages will be evidence based and staff will be trained to deliver a broader range of nice recommended interventions
Principle of ‘no Bouncing’
Staff will have twice as much time to spend with patients
Services will have a recovery focus from day 1. Integrated working will improve the quality of life for service users.
Service users will be able to re access services easily and quickly if they need to.

5. Single Point of Referral
Single Point of Access
Urgent
Routine
Huddle
Triage Team
Single Point of Referral
Non-complex
Clinical Diary
Complex 11
Triage & Action
IRT
Rapid
Response Nurses
UCT
Home Based Treatment
Assessment
Gatekeeping

6. Sunderland Team Configuration
Psychosis and Non-Psychosis
Cognitive
Learning Disabilities

7. Psychosis and Non-Psychosis Teams
Sunderland
x 3 teams
South Tyneside
x 1 team
Psychosis
Psychosis
EIP
EIP
Shared Resource
Step Up hub
Step Up
Step Up
Non-Psychosis
Non Psychosis PD PD
Shared Resource
Psychosis/Non Psychosis
Clinical Leads

8. Cognitive & Functional Frail Teams
Sunderland
South Tyneside
Community Team
MPS
Community Team
YPD
Challenging Behaviour
Step-up / Day Service
Step-up / Day Service
Central Resource
Cognitive & Functional Frail
Clinical Leads

9. Learning Disability Teams
Sunderland
Challenging Behaviour
Physical Health
Mental Health
Learning Disability
Clinical Leads

10. Phased Transition Process
May 14
Dec 14
Current State
Future State
Staffing
Communication
Clinical Risk and Continuity of Care
Caseload Migration
Performance Management
Safety

11. Evaluating PCP

12. PCP Benefits Strategic Driver PCP Benefits Strategic Driver
Improve QUALITY for the patient
PCP Benefits
Improved outcomes and experience
Improved safety
Improved outcomes and effectiveness: Substantially more evidence-based interventions; recovery focus; care pathways and packages; time well spent with patients
Improved experience: patient and carer-centred services; care closer to home in the community; partnership approach; service user and carer involvement in design, collaborative ways of working, easy access and re-access of services
Improved environments: good quality venues, accessible locations
Strategic Driver
Reduce COST
PCP Benefits
Reduced reliance on inpatient beds
Efficient services
Improved flow: Alignment of the pathway across community and inpatient services; fewer admissions; reduced length of stay; better discharge planning; better transitions & partner working; balanced flow of access and discharge
Efficient clinical services: New systems and processes; IT revolution; reduced bureaucracy and waste
Strategic Driver
SUSTAINABLE services
PCP Benefits
Skilled workforce
Partnership and integration
Improved skills: Clinical skills development programme; evidence-based interventions
Improved teams and team-working: Aligned to patient need; new systems and processes; MDT working; team resources aligned to demand
Willing partners and integrators: This can only work well as part of an aligned whole system

13. What to expect - the Numbers (adult and older people)
Current
Future
Community clinicians
% direct time with patients
% time non-patient activity
% record keeping
% Travel
20%
45%
25%
10%
49%
36% 5%
The difference we can make by having more time with patients
Contain patient risk; little opportunity for evidence-based interventions
Focus on a range of evidence-based interventions that support recovery and improved outcomes
System of Access for patients (non-urgent referrals)
Variable system, team allocation meetings, bouncing
Simple, standard system; early allocation of pathway; booked directly; no bounce
Typical Waits
To first contact
Assessment to treatment
4-6 weeks
6 weeks (range 2-10 wks)
1 week
< 2 weeks
% split of resources Community to Inpatient
48% %
60% 40%

14. How will we know what difference has been made?
Quality and Safety Data Suite
Developed by senior clinicians to monitor and measure the impact of transformation across the Trust, designed to answer:
Does the PCP model work?
Have outcomes for patients improved?
Do service users and carers think the service has improved?
Are we delivering more evidence based interventions?
Is there a greater recovery focus leading to reduced reliance on inpatient beds?
Have waiting times reduced?
Are clinicians spending more of their time with patients?
Does the skill mix match demand for services?
Is Transformation safe?
Has there been an impact on out of area referrals?
Has the number of readmissions and re-re-referrals changed?
Are community services contributing to delayed discharges?
Has the average length of stay changed?
What is the impact on community workload?
Has there been an impact on the proportion of incidents?
What has the impact on staff – sickness, morale, vacancy rates?

15. How will we know what difference has been made?
For Service user and Carers:
Service User led narrative interviews. To be carried out over a longer period of time to assess cultural and behavioural changes including: recovery focus, collaboration, co-production, self-management
Satisfaction with services. To assess service user and carer satisfaction with services as delivered at a point in time
Current feedback sources: Points of You, Family and Friends Question
For Staff:
Staff Wellbeing evaluation. To understand the impact of the model on staff morale and well-being
Satisfaction with services. To assess staff feedback on the PCP model covering efficiency, effectiveness, quality and safety of services
Current feedback sources: Staff Survey, Family and Friends Question
For Partners:
Satisfaction with services. To assess the impact of the model on the range of partners we work with including Commissioners, GPs, Social Care and other health providers. To include ease of access to services, satisfaction with service response as well as overall satisfaction with services