Right Care in the right place, human centred care at home and in the community Sally King MSc MCSP NMP Respiratory Specialist Physiotherapist.

Slides:



Advertisements
Similar presentations
What will a cross boundary CCG mean for patients? Colin Renwick, GP Townhead Surgery,Settle. Board Member of Airedale Wharfedale and Craven Shadow CCG.
Advertisements

Suffolk Care Homes An Integrated Approach
Integrated Services Dr Steve Cartwright – Clinical Executive for Integration and Partnerships Andrew Hindle - Commissioning Manager for Integration.
Baseline Model of care for proposed community wards Appendix 1.
Community Hospital Review – The Clinical Model What did we recommend? Dr. David Carson, Director, The Primary Care Foundation.
To care for and treat the patient in the right place with no unnecessary delay or discomfort, by a responsible and empowered workforce.
A whole system challenge -in a challenged system ! South East Essex Health and Social Care.
Hospital Admissions Andy Sharp, Service Director – Adult Social Care Tim Branson, Service Manager - Enablement.
Integrated Nurse Led Respiratory Service Sandy Walmsley RGN, MSc Lead Respiratory Nurse Specialist –Solihull Care Trust Co Respiratory Clinical Lead –
Long Term Conditions Community Matrons and the Respiratory Service: ‘a partnership in the making’ Julie Mountain Lynne White Anne Jones Vicky Walker.
Overview of services provided in Fareham and Gosport by Southern Health NHS Foundation Trust Fareham and Gosport Voluntary Sector Health Forum May 2015.
The Virtual Ward (grasping opportunity!)
Dorset County Hospital NHS Foundation Trust Seven Day Services Working in partnership to reduce avoidable admissions Acute Hospital at Home Patricia Miller,
1 Integration to avoid hospital admission: ITHAcA Sarah Purdy on behalf of the HIT.
Yvonne McWean Lambeth Primary Care Trust 24th February 2009.
Satbinder Sanghera, Director of Partnerships and Governance
ROYAL WOLVERHAMPTON NHS TRUST ADULT COMMUNITY SERVICES LONG TERM CONDITIONS.
Respiratory Benchmarking Packs Yorkshire and the Humber September 2010.
Planning David Bonson April March-May We are here Final draft of plan.
IMPACT (Bath) – bringing primary and secondary care COPD services closer together Claire Bullard Respiratory Physiotherapist.
Preparing for 2018 – NHS priorities and pharmacy service development Sue Sharpe Chief Executive PSNC.
How can COPD Community Services reduce hospital admissions? Glenda Esmond Respiratory Nurse Consultant West Herts Community COPD Service.
Challenges Objectives CCG Led Initiatives Vision ‘How’ Outcome Aspirations Better integrated health and social care Improve the health and wellbeing of.
Programme for Health Services Improvement in Cardiff and the Vale of Glamorgan REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE CARDIFF.
The Health Roundtable Central Network Respiratory Coordinated Care Program Innovation Presenter: Benjamin Kwan Staff specialist respiratory and sleep medicine.
Commissioning the right COPD care for Londoners 7 November 2011 Royal College of Physicians.
The Role of The Specialist Nurse In Respiratory Care Barbara Hanna Respiratory Specialist Nurse South Eastern Trust.
COPD Patient and carers Therapies inc pulm rehab Intermediate care team Social Worker Respiratory Physician EAW/General Physician Case manager/ Community.
Diabetes in Care Homes Dr Nicky Williams Deputy Clinical Chair – East & North Hertfordshire Clinical Commissioning Group Hertfordshire Diabetes Conference.
The Health Roundtable 1-1d_HRT1212-Session_AUSTEN_GOSFORD_NSW Care Coordination decreases hospital reliance-Case Study Presenter: Alison Austen Central.
Western NSW Integrated Care Strategy To transform existing services into an integrated Western NSW system of care that is tailored to the needs of our.
© Imperial College LondonPage 1 Consultants in Integrated respiratory care? Martyn R Partridge Professor of Respiratory Medicine NHLI at Charing Cross.
Domains Care Model HomecareOutpatientsInpatients Primary care.
Influencing Demand – Altering Preload for Canterbury EDs Dr Greg Hamilton Planning and Funding.
COPD and Outreach Services Mandy Dickson Clinical Nurse Specialist Respiratory Outreach Service.
During 2011 COPD in Christchurch accounted for: 1,256 admissions (3.5 per day) 5,952 bed days (two wards in winter) 1 in 4 being readmitted within 28.
Have your say on our plans for Primary Care in Warrington.
Jason Holland 10/06/2013 Changing face of Unscheduled Care The Implementation of new roles within the Emergency Care Directorate across Pennine Acute Hospitals.
Holistic Assessment Rapid Investigation
Emergency Access Information Network - May 2009 ‘Why do people attend’ NHS Forth Valley A&E and what do we need to do to better manage demand’ Kathleen.
COPD Diagnosis & Management Anil Ramineni Specialist Respiratory Physiotherapist Community Respiratory Team.
Long Term Conditions Strategy There are 3 key aims to our improvement strategy: WHCCG has already achieved: – Commissioned Diabetes education through the.
19 Ambulatory Care Sensitive Conditions COPD November 2015.
Dr Jane Gibbins Consultant in Palliative Medicine.
Respiratory Service Framework Asthma and COPD Care (Nursing) Project Learning and Development Strategy.
CfWI produces quality intelligence to inform better workforce planning, that improves people’s lives Wandsworth Virtual Wards - Pilot Project March
Getting the Vision Right: A multi-disciplinary approach to providing integrated care for respiratory patients Dr Irem Patel, Integrated Consultant Respiratory.
Herefordshire CCG Putting the patient at the heart of everything we do1 More information can be found at
Developing Urgent Care Services in Redditch and Bromsgrove Dr Marion Radcliffe: GP and Urgent Care Lead Mick O’Donnell: Head of Strategy.
Sheffield Integrated Care Service Integrated support for complex patients. Sarah Alton Head of Medicines Management Janet Smith Community Matron.
Prevent wounds Adequate risk assessment Use of evidence base to reduce risk Identify overall deterioration Provide equipment advice Actions to mitigate.
Independence and self-management Patients able to self-manage Education on self- management % patients feeling confident or supported (7) Falls – acute.
Think Pharmacy Sue Sharpe CEO PSNC. Outline of Talk The Vision for the future community pharmacy The four domains for pharmacy services  Medicines Optimisation.
The Implementation of a COPD Discharge Care Bundle Louise Sewell Clinical Lead for Pulmonary Rehabilitation & COPD Nurse Specialists Services.
Building the House of Care for diabetes and respiratory conditions in Berkshire West CCGs TIPS January 28 th 2015 Richard Croft, diabetes and respiratory.
Development of a Community Stroke Rehabilitation Team “meeting the need” NHS Blackburn with Darwen Tracy Walker Team Leader.
Evelina London Child Health Programme Integrating services Claire Lemer 29 th April 2014.
PULMONARY REHABILITATION.
Blueprint COPD Services (1/2) 1 Health and Wellbeing Self and Informal Care New Primary Care  New anti-smoking campaign, well-coordinated and consistent.
Healthy Liverpool. Five areas of transformation “Not just physical activity, other factors have to be considered, loneliness, deprivation, housing conditions,
South Essex COPD Psychology Project- Improving psychological well-being in patients with COPD.
COPD Pathway MDM (10new Or 8new 4 FU)
Challenges Vision ‘How’ Objectives Outcome Aspirations
- bringing health and social care together
YMDDIRIEDOLAETH GIG CAERDYDD A’R FRO
A Summary of our Sustainability and Transformation Partnership (STP)
Unscheduled Care Forum September 4th, 2018
National COPD Audit Programme
Claire Vaughan- Head of Medicines Optimisation, Salford CCG
Community Respiratory Specialist Service
Presentation transcript:

Right Care in the right place, human centred care at home and in the community Sally King MSc MCSP NMP Respiratory Specialist Physiotherapist

Gloucestershire Pop’n 620,000 Urban & rural demographic 1 CCG/85 Practices 1 acute provider/2 acute Hosptials 1 community provider 7 community hospitals Coterminous with local authority

National Drivers for Change Fiscal constraints & rising costs Unwarranted variation Quality of care issues (Mid Staffs, Winterbourne View) Ageing population, changing disease patterns and rise in LTCs Changing lifestyles with associated risks e.g. alcohol, smoking, lack of physical activity, poor diet Greater public expectations

External Review Trends Higher overall spend High non-elective spend (although some evidence of flattening) £5.7M non-elective spend on lobar pneumonia (unspecified) & pneumonia (unspecified) + £2.2M on unspecified acute-lower resp. infection vs. £1.8M on COPD Benchmark high on OP activity - 1 st OP attendances & new to follow- up ratio High spend on inahled therapy Benchmark high on average length of stay (Atlas of Variation)

Local context Acute-based Respiratory Assisted Discharge Team Community Respiratory Team: Pulmonary Rehab (300 pa) Telehealth (large-scale/1000 & specialist/200) Medicines optimisation Exacerbation management Home oxygen assessment service Medicine Use Reviews (community pharmacies) Admission and discharge bundle for COPD project

BUT…Not joined up Multiple hand-offs Replication Inefficiency/increased cost arising from: increased lengths of stay increased/unnecessary admissions increased OP/follow-up referrals & appointments increased primary care consultations inefficient deployment of staff ++ burden of care for (unwell) patients

Decision to integrate acute and community resp services Gloucestershire Respiratory Team: Will operate as a single, cohesive MDT (providing PR, assisted discharge, oxygen services, telehealth etc) Will have single organisation lead Will have clear clinical leadership & governance arrangements operate to agreed, clear/unambiguous eligibility & referral criteria Will have a single point of access Will be truly primary care facing/supporting (incl. training & education) Will have the freedom to innovate (e.g. COPD ‘hot clinics’, telehealth, phone advice etc) be fully integrated with: Hospital-based services Prevention services e.g. Stop Smoking End of Life care/services Integrated Community Teams Community pharmacies

The prize Improved quality of care for our patients More engaged and motivated workforce (appropriate use of skills) Potential to expand into other disease areas e.g. CAP/bronchiectasis Potential to use the model for other disease areas ?? CHD, diabetes etc

9 Packages of Care Urgent Assessment Exacerbation Management Urgent review within 72 working hours Weekday 8:30-4:30 cover (currently) Urgent Assessment Exacerbation Management Urgent review within 72 working hours Weekday 8:30-4:30 cover (currently) Symptom management Respiratory medicines advice Non urgent response within 14 working days Symptom management Respiratory medicines advice Non urgent response within 14 working days Home Oxygen Assessment Service Community service CBG and pulse oximetry Respiratory Physicians supports Home Oxygen Assessment Service Community service CBG and pulse oximetry Respiratory Physicians supports Pulmonary Rehabilitation Countywide Service 7 week course 2x 2hour sessions/week Multi-disciplinary Team Pulmonary Rehabilitation Countywide Service 7 week course 2x 2hour sessions/week Multi-disciplinary Team Specialist Telehealth 90 units Patient selected by GRT Patient Case Managed Admission avoidance Reviewed every 3 months Specialist Telehealth 90 units Patient selected by GRT Patient Case Managed Admission avoidance Reviewed every 3 months Early Supported Discharge Reduces LoS <7 days Patients remain under Consultant care Supported for up to 14 days Early Supported Discharge Reduces LoS <7 days Patients remain under Consultant care Supported for up to 14 days Supported Discharge Complex respiratory needs Non resp. wards supported GRT support up to 3 months Discharged back to GP Supported Discharge Complex respiratory needs Non resp. wards supported GRT support up to 3 months Discharged back to GP Nurses led Outpatient Clinics OP Clinics in GHT and community setting Supporting Respiratory Physician clinics Nurses led Outpatient Clinics OP Clinics in GHT and community setting Supporting Respiratory Physician clinics Specialist respiratory advice Other respiratory diseases supported e.g. Asthma, Bronchiectasis Close links with Respiratory Physicians Specialist respiratory advice Other respiratory diseases supported e.g. Asthma, Bronchiectasis Close links with Respiratory Physicians

Telehealth 100 units Tool for identifying changes in the most respiratory vulnerable patients Criteria Frequent exacerbations Frequent users of service Geographically remote Live alone Step up/step down options between primary and secondary care Ability to use post discharge for short period

Specialist Team directly support RR Specialist Team support ICT Specialist Team advice and support Case Manage.

What next Continue to engage the wider team Develop case management workstreams using integrated care approach Work with academia to develop telehealth algorithms to reduce false alerts Adopt this approach in other disease areas i.e bronchiectasis, ventilation services, ILD Evaluate PREPARE model Develop Severe COPD clinics with representation from integrated team