Right First Time: Update

Overview Making sure Sheffield residents continue to get the best possible health services is the aim of a new partnership between GPs, local hospitals, mental and community health teams, the City Council and voluntary organisations. The Right Care, Right Time, Right place partnership is particularly focusing on transforming and improving the way older people receive healthcare and also those patients who have long term illnesses such as diabetes, heart failure and dementia.

Vision To ensure all Sheffield’s residents live longer and healthier lives, and are supported in their local community wherever possible by joined up, high quality, responsive, health and social care services which offer continuity of care, shared decision making, and a lifelong, personalised, preventative approach to health and wellbeing.

Phase 1 Update: Key Aims To improve the clinical outcomes for older people with complex needs To make better use of limited resources To improve patient experience TRANSFORM THE HEALTH AND SOCIAL CARE SYSTEM TO BE LESS HOSPITAL CENTRIC

Phase 1: Key area of focus Age, frailty and complex needs Reducing avoidable admissions and reduce long stays in hospital Improving the capability and capacity of health and social care services in the community to support older people

The approach Phase 1 of the Right First Time programme has been split into 3 projects which have begun to deliver real benefits to patient care and the start of the transformation journey across the health system.

Project 1 Project 1 has focused on the development and prototyping of integrated care teams (ICTs) that align with the emerging GP Practice Associations, enabled by Risk Stratification, Assistive Technology and Self Care.

Project 1: GP Associations Discussions around the concept of GP Practice Associations have been taking place over the last year and practices are now starting to align themselves into groups of between 30,000 – 40,000 patients with a view to creating more integrated working with other Health and Social Care resources within the community. 16 associations have been identified across the 4 CCG Localities Hallam and South, Central, West and North). The emerging associations have started to meet and early discussions have identified some opportunities for working together.

Project 1 – Integrated care teams District Nursing services being aligned around the emerging GP Practices associations and these will form part of the core of the new integrated care teams. A reorganisation of the Assessment and Care Management Services (SCC) has also taken place aligning with GP Practices. Further work has now commenced to explore the next phase of development for the Integrated Care Teams and how they will incorporate Social Care activities. Initial discussions have also taken place with Community Mental Heath and Community Pharmacy to try to identify possible links and ways of working.

Project 1: Integrated care teams Project 1 is working closely with a number of on-going pilots across the city (including Low Edges, Batemoor and Jordanthorpe) and supporting the development of other prototypes within GP Associations, for example the recruitment of Community Support Workers to provide the interface between Health and Social Care.

Project 1: Risk stratification The combined predictive model of risk stratification has been rolled out to 98% of GP practices, allowing them to identify patients of high and emerging risk of admission to hospital. Will enable GPs to then work with other health and social care professionals to put interventions in place to support these patients. Further analysis is required to understand what actions practices are taking as a result of using this tool and impact on patient care and outcomes.

Project 1: Impact so far 95% of the registered population is now risk stratified Significant alignment in place for primary and community services (health and social care) Some testing for how Integrated Care Teams could work

Project 2 – ‘redesigning the front door’ Project 2 has focussed on redesigning the ‘front door’ response (e.g. Frailty Unit) at STH by reducing the number of elderly admissions and by completing comprehensive assessments at the point of referral and developing consistent thresholds for admission.

Project 2 – ‘redesigning the front door’ The development of the Frailty Unit by Sheffield Teaching Hospitals at the Northern General Hospital was undertaken with support from the The Health Foundation and partners across the Right First Time partnership. All consultant geriatricians at Sheffield Teaching Hospitals changed rota pattern to 7 day working at the front door from 1 st April The Frailty Unit launched virtually from beginning of May and in physical form from mid-May. There was wider system development in the Community under the Right First Time projects that facilitated the flow. Results from April to September 2012: Reduction in bed usage by Geriatric medicine (medical outliers reduced rather than bed closures) by over 60 beds. 16% reduction in readmissions 13% reduction in raw mortality

Project 2: crisis prevention In conjunction with project 1, project 2 has also been developing services to provide better response to crises, particularly for residential/nursing homes. For example the expansion of the falls service (the number of interventions rising from 1,682 to 3,364 in12/13). Q1 data shows falls admissions have reduced significantly.

Project 2: Impact so far Early success with reducing some avoidable admissions of the frail elderly. Improved mortality rates, reduced length of hospital stay and reduced readmission rates for frail elderly patients who need emergency care.

Project 3: Impact so far Streamlined discharge process for complex patients Reduced number of patients with long lengths of stay Fast track process for patients going into long term care, though the Sheffield rates are higher than average Better in reach services for patients with dementia

Phase 2: the plan for the next 3 years Broaden the scope to include mental health, children’s unscheduled care (in conjunction with Future Shapes) and parts of planned care Raise the ambition to significantly reduce avoidable emergency admissions in the next three years (based on achieving an optimally performing health and social care system in place). Aim for further integration of community services to manage the re-alignment of care more proactively

Phase 2: the Plan for the next 3 years Public communication and engagement programme developed Reference group made up of members of the public, patients, carers etc. being established Oganisational development strategy being developed. IT strategy being developed

Questions