1. Community Rheumatology
Erica M Gould RGN DipN MSc INP
Rheumatology Nurse Consultant
Modality Partnership
October 19th 2018

2. Introductions & Objectives
Understanding of Modality Partnership and what the rheumatology service offers
Describe how the service was set up and commissioned
Understanding of the how the service fits with the local health economy including secondary care
Understanding the nursing role within the service
Future vision for the service

3. Modality Partnership 3 miles north of city centre
Geographic radius of approx 15 miles
Existing primary care outlets ( Right care right here)
Super-partnership with population of 70k – increasing
Key membership of CCG Board
One of 14 sites chosen for Vanguard status ( Integrated Care Organisation )

4. Community Rheumatology
Pilot project in 2009 – one location
GPWSI / Nurse Consultant initially looking at stable patients who could be managed in primary care and a MSK triage to avoid unnecessary referrals to secondary care

5. Rheumatology Service Staff
Self managing / self governing
GPwSI X 3
Nurse Consultant x 2
Nurse Practitioner
Extended Scope Physio
Pain service physio and Psychologist
Visiting consultants x 5 – SLA
Administrators x 2

6. Key Performance Indicators
New patient referral 2 weeks (max 4) 100%
Flare work 100% 5 working days
Helpline calls 1 working day
Onward secondary care referral rate less than 5%
IA disease control with low measures 18 months
New to follow up ratio 1:2 (less than 5% 3 visits)
Satisfaction 100% new pts surveyed, 100% of follow ups

7. Community Rheumatology Service
Care is delivered at 80% of tariff
High end triage
Nurse-led follow up
Treat to Target
CQRA
RA QOF
MTD
Community and third sector engagement
Care pathways for all disease groups
Proms / Prems
Research Involvment

8. Community Rheumatology Service
Web based IT systems with excellent reporting capabilities
Able to population search across the organisation i.e. psoriasis / joint pain/ back pain which may enable early detection of PSA
Modality Community Dermatology Service
No restriction on choice of biologic

9. Community Rheumatology Service
BSR presentations /poster Publication in conjunction with NRAS / CQRA NRAS award

10. Nurse Consultant Role Expert clinical care Leadership Education
Research & Audit
Service development

11. Outcomes – General
Team built from grass roots personnel specially selected
Academic research unit
CQRA outcomes/Dashboard
Patient outcomes in development
Non user patient feedback
Community education in development
Dialogue through newsletter

12. Benefits to Local Health Economy
Fits in with National policy
Cheaper tariff
Right time, right place, right person, right care
Target hard to reach populations
DNA policy
Clinical tracking
Less bureaucracy

13. Integration Relationships Competition
Secure referral base for clinical care and research
Up- skilling primary care
Joint meetings
Access to shared records via IT links

14. Limitations Infrastructure / IT
Growth of organisation / constant change
New approaches to employment of staff
(other providers)
Differing pathways i.e. biologics`

15. Service expansion Audit data Jan 2014 Nurse cohort 429
Audit data Jul Nurse cohort 948

16. Service Expansion
Clinics held in 13 health centres across Sandwell and West Birmingham
Established links with third party sector and other agencies
Integration with local NHS trusts ( no longer considered a threat)

17. Nurse Managed Cohort (N=948)
Modality Partnership audit data July 2018

18. Vision for Future 2 years clear commissioning intention –
Integrated Care Organisation status
5 years : - Patient focus
Patients working
Low disease / remission
Minimal delay
Demonstrate lower follow up ratio after 2 yrs
Lower drug bill
Centre of Excellence for Primary Care Research
New roles – Succession planning / nursing development

19. Advice to others Educate your commissioners Know your business
Be nice to each other
Utilise all resources ( people , places)
Exploit / develop secure IT options
Change is not a threat it is an opportunity
Speak to us !

20. Relevant Reading : Transforming our health care system Kings fund 2011
White Paper 2008 “Care closer to home”
Right care Right Here
Securing the Future of GP Practices – New Models of Primary Care – Kings Fund 2013
Five Year Forward View – NHS England 2013

21. Thank you