1. Walsall Interface With Secondary Care Trish Skitt 13, Nov 2003 Birmingham Evercare Event

2. Agenda PCT and Secondary Care Background Business Case Scenarios Secondary Care Interfaces – Notification of hospital admission – APN and consultant mentoring – HAT tool process – Monthly business/clinical meetings Most challenging and support for change in implementing Evercare programme in Walsall Discussion

3. PCT Background 1700 Employees 255,000 population 14% (41,422) > 65 years old 121 GPs total in community High number of single-handed GPs 36 GPs (11 GP Practices) involved in Evercare 1 primary hospital-785 beds Incorporate MH Star Ratings

4. Secondary Care Background 90% of Walsall patients go to this hospital Focused on reduction of avoidable hospital admissions 3.36% of the high risk >65 drive 46% of unplanned admissions Director of Nursing and consultants support IT initiative to link all systems together

5. Possible impact? Total high risk patients 1276 Total unplanned admissions 3,246 Length of Stay14.65 Cost per day£209 Cases per APN50

6. Managing capacity Meeting targets More effective utilisation of geriatrician consultant time – Discharge planning – Shared learning Coordinated diagnostic/medication management Knowledge of patients pre-hospital status Interface of primary and secondary care Whats in it for Secondary Care?

7. Hospital Notification Process System-wide IT Initiatives – Fusion Project – PMS Access – Status Messaging Evercare cohort list/APN sent to hospital IT Automatically notifies APN of hospital attendance – email – mobile phone

8. APN and Consultant Partnership 4 nurses paired up with 4 Geriatric Consultants Visit and conduct wards rounds together Good hospital support for documenting notes in hospital medical record Work in partnership with discharge planning team to streamline LOS and share learning

9. Partnership Success Stories Admission Avoidance – APN called consultant who made a domiciliary visit – Nurses confidence – Averted hospital admissions Shortened length of stay Enhanced quality of life Increase in functional status Pharmacy Management

10. HAT Tool Process Started process in Sept Multi-disciplinary team – Chaired by Clinical Lead – Consultants, GPs APNs, Social Services – Team meets monthly to discuss Evercare cohort admissions and determine root cause – Shared learning – Action plans created Will categorize admissions monthly to trend

11. Monthly Business Meetings Team of clinical and management Shared agenda Shared success stories Communicate data results (once available) Issues/barriers Future actions

12. Most challenging aspects implementing the Evercare Programme Modernisation agenda of PCT/Secondary Care Supporting framework Not more of the same Engaging critical mass of GPs Confidence for service re-design Primary Ownership Milestone

13. Supporting the Change Level of local commitment/leadership – Commissioning function – Quality of patient care – Audits Support and enthusiasm of Evercare team PCT structures mirror national strategy – Assists whole systems approach – Person Centred Care – NSF Enthusiasm, skills, confidence of appointed nurses Communication of patient diary events

14. Questions/Discussion