1. Integrated Services Dr Steve Cartwright – Clinical Executive for Integration and Partnerships Andrew Hindle - Commissioning Manager for Integration

2. Dudley CCG: context  CCG registered population = 312,000  47 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.

4. Dudley Health and Social Care Economy – The Opportunity  Unnecessary emergency admissions  Too many admissions to nursing and residential care  Recognition by partners of the need to address through a step by step change in service delivery  Commitment to redesign urgent care  Evidence that 5 day working creates dysfunctional service pressures

5. Integration and 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

6.  Dudley was successful in applying to be one of the National Early Adopters  Cross health economy working group set up  Working with NHS Improving Quality Team Three main areas of focus  Mapping of services  Developing community standards  Sharing best practice with other early adopters 7 day services

7.  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…..

8. Community Mental Health Teams: adults and older people Palliative care team Heart failure- joint pathway with acute OT Physio Care home nurse practitioners Stroke Neurology Social 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)

9. 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

10.  Team of 9 Advanced Nurse Practitioners (ANP)  Integrated with social care assistants and care home nurse practitioners  ANPs take a referral or co-respond with West Midland Ambulance Services  Assess, diagnose, initiate treatment, instigate social care package if required and refer to integrated teams Community Rapid Response Team

11. Community Rapid Response Team for Older People with Frailty Integrated with Care Home Nurse Practitioners and Social Care Assistants PATIENTS WMAS NHS 111 WMAS NHS 111 GP Out of Hours Community Nursing Teams Assessment by ANP or Care Home Nurse Practitioner Within one hour Assessment by ANP or Care Home Nurse Practitioner Within one hour Step down to Locality Integrated Teams Single Point of Access for Advanced Nurse Practitioner Based at WMAS Single Point of Access for Advanced Nurse Practitioner Based at WMAS Admit to EAU Admit to EAU - Initiate treatment → - Initiate care package → up to 7 days (then review) - Initiate care plan - Initiate treatment → - Initiate care package → up to 7 days (then review) - Initiate care plan

12. Practice integrated teams  To consist of GP, pharmacists, community nurses, named social and mental heath workers.  To review risk stratification tools and agree a Care Coordinator for complex cases  GP Leadership posts in each locality Service Integration

13. Infrastructure for integration  A comprehensive organisation development programme  A common Information Technology platform  A common approach to care planning  An agreed performance framework

14.  Over 2,200 residents in nursing and residential homes registered with a Dudley GP  High number of urgent care admissions  Dudley Care Home GP programme 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

15.  Proposal is to have a Single Point of Access phone number for community health and social care services  To include a fourth option where there is more than one problem/issue and requires triage.  This will enable effective triage and the call handler takes on the role of a facilitator rather than navigator. Single point of access

16.  Develop self care programmes  Develop technology including remote monitoring tools (tele-health)  Increase utilisation of voluntary sector (community link workers)  Social prescribing Prevention agenda

17. Palliative and end of life care  Investment in palliative care services including a new palliative care consultant  Practice identifying more people in their last year of life to ensure a multi-disciplinary team approach and support  Increase and standardised approach to advanced care plans  More people at end of life having choice of preferred place of care

18.  Patient perspectives addressed via the health economy Integrated Working Group  Aim is to capture the actions and improvement that need to be implemented.  Feedback given to the patient, carer or advocate that provided the story/experience. Learning from patient experiences

19. Questions?

20. 1.In your case study what elements of the service worked well? 2.What elements didn’t work well? 3.What could have worked differently?