wandsworth community adult health services specification · 2013. 10. 9. · older people –...

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. Wandsworth Community Adult Health Services Specification

Wandsworth Community Adult Health Services Specification

Authors

Name Job Title

Dr Seth Rankin Clinical Service Lead for Out of Hospital Programme (WCCG)

Claire Ratnayake Head of Clinical and Service Improvement (WCCG)

Andrew McMylor Director of Delivery and Development (WCCG)

Table of Contents

1. Introduction ..................................................................................................................... 3

2. Aims and Objectives of the Redesign ............................................................................. 8

3. Detail of Systems and Processes - Meetings .................................................................. 9

4. Management Structure of Community Adult Health Services ........................................ 14

5. Key Worker Concept ..................................................................................................... 14

6. Operating Hours for Functions ...................................................................................... 16

7. The Seven Functions of Care in More Detail ................................................................. 18

8. Services Aligned with the Functions .............................................................................. 30

9. Out of Hours Provision – across all functions ................................................................ 32

10. Information Technology .............................................................................................. 32

11. Estates........................................................................................................................ 32

12. Further Expectations of Provider ................................................................................. 34

13. Conclusion .................................................................................................................. 34

Contributors

Name Job Title

Dr Andrew Neil Consultant Geriatrician. Medical Director Community Services Wandsworth. Secondary Care Doctor WCCG Board

Alison Benincasa Associate Chief Operating Officer Community Services Wandsworth. Older People & Neurological Rehab services (SGH)

Dr Rod Ewen Clinical Lead for IT & Battersea Locality Lead WCCG

Nick Beavon Head Pharmacist WCCG

Patient Groups From CRG’s, Commissioning PPGs and workshops

Professional Groups Community Services Wandsworth, Wandsworth Borough Council, Commissioning Redesign Managers, St George’s Acute Services, Harmoni/111, Community Mental Health Team, Voluntary Sector

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Table of Figures

Figure 1: Patient Overview of the New System ..................................................................... 5

Figure 2: Community Adult Health Services Functions Overview .......................................... 7

Figure 3: Weekly MDT configuration ................................................................................... 11

Figure 4: Risk groups .......................................................................................................... 15

Figure 5: Overview of operating times within each function ................................................. 16

Figure 6: Community adult health services: Health ............................................................ 18

Figure 7: Community adult health services: Social Care – located in Wandsworth Social

Services .............................................................................................................................. 19

Figure 8: Rapid Response Pathway for Locality Teams ...................................................... 20

Figure 9: Hospital Discharge and Community Discharge Teams Pathway .......................... 22

Figure 10: Maximising Independence Pathway ................................................................... 24

Figure 11: Complex Case Management Pathway ............................................................... 26

Figure 12: Scheduled and Ongoing Care Pathway .............................................................. 28

Figure 13: EoLC Patient Family and Carer Needs ............................................................... 31

Figure 14: Indicative Estates Required for the Delivery of the Functions ............................. 33

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1. Introduction

Wandsworth Clinical Commissioning Group’s proposed new model for Community Adult Health Services (CAHS) is ambitious, achievable and essential. It will improve the delivery of care for people in their own homes by interlinking systems to enable staff to work more effectively. This document is a summary of the commissioner’s vision for how community adult health services will look in 5 years’ time but is intended to develop dynamically and pragmatically during 2 years of implementation. With the increasing health and social need in our aging population the centre of gravity for care needs to shift to people’s homes and away from more expensive and less appropriate locations such as secondary care. Our population expect this and the health and social care economy demands it. However if people are going to be cared for out of hospitals we must have improved community systems for this to be safe. Improving access between primary care and community adult health services has been a central theme but even more important has been ensuring interlinked systems between secondary and community care to ensure timely, safe transfer from hospital to home to address the rising tide of unnecessary ‘default’ admissions in all our local hospitals. This integration is essential for patient/service user safety and experience and the financial feasibility of the entire health and social care system. It is apparent to keen observers that in the ‘trinity’ of healthcare services comprising secondary, primary and community services; community services have traditionally been commissioned in an ad-hoc and reactive way. This redesign is an integral part of an entire whole-systems approach which includes secondary and primary care transformation and cannot be uncoupled. It is a hugely ambitious task but improving community adult health services’ ability to deliver care is vital and radical solutions are essential. The new environment with clinically led commissioning, the mandate for health & social care integration and joint funding initiatives under Health & Wellbeing Boards present an exciting opportunity to develop and implement an entirely new way of working together for our patients/service users. Wandsworth Adult Social services are undergoing an extensive review of the way they deliver their services which has been extensively referred to in this primarily health led specification. Consultation between health and social services is ongoing and the services will continue to be further integrated so the service user/patient is able to have their care needs delivered by a seamless service wherever there is overlap of need. Consultation and experience demonstrate that health and social services available to people in their own homes are hampered mostly by organisational problems which are multi-factorial in their origin and are assumed to be self-evident for the purposes of this document. This document summarises what has been distilled from many months of consultation from all stakeholders involved. Subsequent extensive work-shopping by senior clinicians and managers with many years of experience in the use, delivery and management of community health and social services has refined the model. Its appendices include even more detail of the systems and processes expected from the provider than is contained within this document for which we offer no apology. It is essential that the overall vision and insight that has been gleaned from the extensive once-in-a-lifetime opportunity to take all stakeholders’ views into account is captured in its entirety. It is expected that these expectations form the basis of ongoing development with the provider and pragmatic adaptations will take place during implementation and beyond.

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There have been some admirable innovations and progress within Wandsworth Community Services over the last few years and this specification draws directly from the lessons gleaned from these pilots and projects. In particular the Community Ward where the immense challenges inherent in multi-disciplinary and flexible working have been highlighted and overcome to a large extent. Of note too is the experience of the Intermediate Care team and its ability to target discharge. It is essential that these services (and many more) are expanded, made easier to access and become fully integrated into the daily working of the entire community system. This document expresses the situation within the health services and proposed solutions more comprehensively than it does the plans for social services redesign which are also well underway. The redesign of both services are running parallel and for the first time with this redesign health and social services will be sharing office space and health staff will be delivering packages of social care via the trusted assessor role. The redesign addresses the following overarching challenges:

improving access to community adult health services for patients/service users and all health and social service professionals who need assistance to maintain care for people in the community.

developing a complete service that has the necessary resources to provide full multidisciplinary care in patient’s own homes, integrated and interlinked with primary, secondary, social & voluntary care agencies - but not entirely dependent on them to deliver the care needed.

enabling seamless and timely discharge from hospitals to home and interlinking between secondary, primary and community care systems.

enabling effective management of human and other resources within the community with reference to how to monitor and manage a mobile and independently minded workforce

providing a platform where secondary care specialists (such as geriatricians) can integrate with and support community adult health services.

enabling ready access and integration for primary care, social services and voluntary sector with the services and skills of community adult health services staff.

This new model is intended to subvert the traditional medical model where care is delivered by teams dedicated to a specific operational or disease pathway. It facilitates the capacity to meet a person’s care needs wherever possible by any member of any team that has the capacity and capability. Rather than start with what we professionals believe is needed by our population we started with patient/service user needs and grouped these needs or activities into ‘functions of care’.

Functions of Care Approach The Seven Functions of Care:

Access and Coordination

Rapid Response

Facilitated and Supported Discharge

Maximising Independence

Complex Case Management

Specialist Input

Scheduled and Ongoing Care Of course it is also essential to good clinical care that specialist services and disease specific pathways exist within these functions. Ensuring that both these paradoxical aspects are addressed within the same specification has been an invigorating creative challenge for

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the authors and one of the key reasons why effective community adult health services redesign is difficult.

Care will embrace the person rather than expect them to struggle onto a rigid pathway in order to have their care needs met. The functions will be aligned around the person and react to their individual multi-factorial needs.

Figure 1: Patient Overview of the New System

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The next diagram expands further how the functions of care will operate to deliver the care patients/service users need and how the functions will be accessed by professionals who rely on community adult health services to assist them in keeping people safe and healthy at home.

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Figure 2: Community adult health services Functions Overview

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2. Aims and Objectives of the Redesign

To deliver care to the right people in the right place at the right time by the right people doing

the right things in the right way with the right tools and the right support…

To provide high quality, fully integrated, multi-professional, community-based service meeting people’s urgent, intermediate and on-going health care needs.

To reduce service fragmentation and ‘hand offs’ in an individuals’ care pathway.

To dissolve complicated referral pathways, difficult access criteria and single pathway approaches to care.

To foster a “yes service” culture focussed on the needs of the patient/service user.

To enable patients/service users to remain well and independent in their own home wherever possible.

To be a single point of contact accessing all available community care services, professionals and volunteers.

To deliver person-centred, multidisciplinary, skilled and seamless care.

To provide pro-active and anticipatory case management.

To provide a reactive service delivering acute interventions when necessary.

To operate as one service, from both a clinical and a patient/service user perspective.

To be a platform providing access for all stakeholders: secondary, primary, voluntary sector care providers as well as patients/service users and their families and carer.

To facilitate safe and rapid discharge home if an admission is ever necessary.

Geographical Coverage Community adult health services will be available to all relevant patients/service users registered with a Wandsworth GP living within ½ mile of the Wandsworth borough border. All GP practices (currently 44) in Wandsworth will be aligned to one of four (4) geographical Locality Teams. Service Scope

Dietetics

DESMOND

Community Nursing

Primary Care Therapy Team (St John’s Therapy Centre)

Intermediate Care Services

Wandsworth Integrated Equipment Services (WICES)

Specialist Respiratory Nursing Service

Specialist Heart Failure Nursing Service

Specialist Leg Ulcer Nursing Service

Specialist Diabetes Nursing Service

Older People – Cardiac Rehab Nursing Service

Community Pharmacy Asthma Support Project

Older People – Oxygen bid The following are currently excluded from this specification for various reasons which may be open to negotiation:

Community Neurological Rehabilitation Team

Integrated Falls and Bone Health Team

Women and children’s services

Bed-based services

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Health visiting services.

3. Detail of Systems and Processes - Meetings

To ensure handover of on-going patient/service user care needs, to maintain effective oversight of staff, to robustly oversee and monitor the implementation and on-going functionality of the whole system the Provider will incorporate the following meetings within their operational structure. Regular meetings have not always been an essential feature of community adult health services structure and the experience of the community ward has demonstrated the immense value of having them. It has also demonstrated the resistance and difficulty in maintaining the convening of meetings, which is why the detail has been mandated in the specification. Occurrence and minimum attendance registers for all meetings below will be a KPI.

Daily Handover Meeting (9:00am)

There will be a daily morning handover 7 days a week, 365 days a year where core members of the multidisciplinary team will liaise together as a locality team.

Based in locality headquarters/estates

Face-to-face where possible or virtual via teleconferencing where not.

Clear structure to the daily meeting consistent across all four locality teams.

This meeting should be succinct and should last approximately 30-45 minutes

The overall purpose is to: Update team with changes in a patients’ condition overnight and assess and assign the team’s tasks for the day

Attendance Required

Locality Manager

Assistant Locality Manager (chair)

Senior Administration Manager

Occupational Therapist and Physiotherapist – Maximising Independence

GP – Complex Case Management/Matron

Matron and Social worker – Complex Case Management

Community Nurses – Scheduled and Ongoing Care

Facilitated and Supported Discharge - (Community based team leader)

ANP – Rapid Response

Specialist Nurses – 1 from each of Respiratory, Cardiac, Diabetes, Tissue Viability and Dementia

Roles & Responsibilities of Team Members

The Locality Manager and Chair are jointly responsible for the prompt time keeping and record of attendance and ensuring all updates are entered on the shared notes system that can be accessed by all staff. The monitoring and reporting of attendance forms a KPI.

The Facilitated and Supported Discharge function (F&SD) will update the team on any proposed discharges into the locality for that day and any information they need, dependent on which function will be taking over the coordination of the patient/service user’s care.

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Rapid response (RR): The ANP from the Rapid Response function will update the team on any patients that remain under the care of the RR function and still require on-going acute review.

Scheduled and Ongoing Care (S&OC) Trained Nurse: The other function’s representatives will update the Nurse from S&OC if they plan to move a patient/service user to S&OC. The S&OC Nurse will then be responsible for handing this information to the shift co-ordinator for S&OC to ensure this visit is scheduled into the teams’ activity. The S&OC nurse will hand over patients to other functions when needed at this meeting as well.

Business Continuity Representatives from each function will report any capacity issues due to unplanned sickness absence/leave to the Assistant Locality Manager thus enabling a dynamic solution to be implemented and for management to be able to consider whether it is necessary to invoke the business continuity procedure for Community adult health services.

Weekly Multi-Disciplinary Team Meeting

There will be a weekly MDT meeting at a time to be determined by the Provider. To be held in a central office and attended in person rather than telephonically wherever possible. Attendance of core team members will be a KPI. Core Members - 100% attendance required

Community Services GP (Chair)

Assistant Locality Manager

Occupational Therapist and Physiotherapist – Maximising Independence

Matron and Social worker – Complex Case Management

ANP- Rapid Response

All Specialist Nurses required, Respiratory, Diabetes, Cardiac, Tissue Viability

Pharmacist

Community Nurses - Scheduled and Ongoing Care Non-core members - % of attendance to be negotiated with Provider

• Consultant Geriatrician - attendance fortnightly rotating amongst the four locality MDT’S • Registered Wandsworth GPs • Community Mental health Team (CMHT) • Palliative Care Nurses (Trinity Hospice) • Age UK (Voluntary sector) Structure A consistent structure to the MDT meeting which will be adopted by all four locality teams. The chair (GP) of the weekly MDT will be responsible for:

Providing structure and engaging all staff present to participate appropriately

Leading on a review of patient goals and agreeing management plan The objective of the MDT discussion

Review patient goals and ensure appropriate movement between functions and to wider whole-system (e.g. to patient’s GP or secondary care)

To facilitate effective working between the functions

Patients/service users to be discussed will be timetabled appropriately to allow for best use of staff resources.

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Figure 3: Weekly MDT configuration

Shift Handover Meetings (three times a day)

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The Community Nurses from S&OC will schedule a handover meeting at the end of every shift (three times a day). One of these meetings will be the 0900 morning handover meeting outlined above.

Morbidity and Mortality Meeting

Mortality and Morbidity (M&M) meetings will be monthly in each locality for staff to review:

Recent deaths

Serious adverse incidents/adverse incidents

Hospital Admissions

Near misses

Complaints

AOB This meeting will be held in the locality headquarters and will be attended by representatives from all functions.

Clinical Quality Review Group (CQRG)

A monthly meeting for commissioners and providers to review clinical quality will be held. Membership

Head of Clinical Patient Safety and Clinical Governance for WCCG

Associate Director of Operations for Community Services

Director of Nursing and Clinical Governance for Community Nursing

Medical Director –Community Services

Locality Mangers - in their absence Assistant Locality Managers

A GP representative for each locality

Lead for Quality and Assurance

Head of Compliance and Assurance (SGH)

Designated Adult Safeguarding Lead for Community Services

Medicines Management Representative

Head of Customer Care and Experience (SGH) Representatives from other departments/services may be invited to attend as appropriate

Quorum At least six members of the group including: either the Medical Director or the Associate Director of Operations for Community Services, Director of Nursing and Clinical Governance, a GP, at least two Locality Managers and the Head of Quality and Assurance. Points for discussion/review

Patient safety incidents.

Serious Untoward Incidents including unexpected deaths within Community Services.

Trends which require urgent remedial action and the implementation of any clinical action plan.

To review and approve policies in relation to the performance management of quality issues within Providers.

Provide an overview of any joint open complaints and progress in addressing them (patient non-identifiable).

Provide an overview of any Joint Clinical Investigations that are currently open.

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Review patient satisfaction feedback.

Provide an overview of open safeguarding incidents under investigation (patient non-identifiable).

To review any day to day operational issues that could raise a risk to patient safety.

Review of staffing- skill mix to provide assurance to the commissioner that current levels are safe for caseloads being managed and that they comply with any evidence-based and workforce assurance tools.

Any points of operational concern regarding patient pathways that are raised in the local Clinical Reference Groups must be discussed by this group to ensure a patient voice is represented.

Clinical dashboard: A clinical quality dashboard will be devised jointly between the Provider and the Commissioner which will consider the key findings of the Francis Report. The group will scrutinise Provider performance against the community services contract. The Provider will also be required to expediently produce evidence of any required risk assessments agreed as necessary by the membership. The membership for this group will be reviewed regularly and amendments made as required.

Business and Operations Reference Group Meeting

A monthly meeting to formulate measures of performance and monitor jointly progress against expectations and to address any unforeseen issues developing either financially or operationally during this major transformation of an essential service. As this is an untested operating model for Community Adult Health Services the pre-set activity targets will require close scrutiny. Commissioners and Providers need a forum to review the KPI’s set and remain open to ongoing negotiation as required. Membership

Director of Delivery and Development (Wandsworth Clinical Commissioning Group)

Clinical GP Lead for Community Service Re-design (Wandsworth Clinical Commissioning Group)

Head of Clinical and Service Improvement (Wandsworth Clinical Commissioning Group)

Head of Business Development for Community Services (Provider)

Head of Contracts for Community Services Business Development Manager (Provider)

Project Managers for Community Services (Provider)

Divisional Chair (Provider)

Medical Director (Provider) Quorum At least 4 members of the group need to be present and this must include any of the below. However this must include a minimum of 2 Provider staff and 2 Wandsworth CCG staff:

Director of Delivery and Development (Wandsworth CCG)

Head of Clinical and Service Improvement (Wandsworth CCG)

Clinical Lead (Wandsworth CCG)

Divisional Chair (Provider)

Associate Director of Operations (Provider)

Head of Business Development (Provider) A Business and Performance Dashboard and Risk Registers will be developed, maintained and monitored.

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4. Management Structure of Community Adult Health Services

The newly redesigned Community Adult Health Services will operate a management system with accountability for different staff groups within the varying functions. The Locality Managers are required to work with Social care colleagues as required to address activity and operational issues for their Locality on a daily basis. The appendices contain a diagram illustrating the reporting lines and management structure within each function.

5. Key Worker Concept

Key-worker contact for patient/service user and family and carers Patients/service users will be assigned a key worker to be the point of contact for any queries that the patient/service user or family and carers may have. The over-riding care need of the patient/service user will determine the most appropriate professional to be assigned as the key worker: For example:

Over-riding Need Professional assigned to key worker role

Decreased mobility Physiotherapist/Occupational Therapist

Clinical instability Matron/Senior Nurse and/or GP

Social Care Needs Social worker or Matron/Senior Nurse

Identifying Risk Levels in patients/service users

Patient/Service Users will be stratified according to whether they are high, medium or low clinical risk. Depending on their stratification they will have different levels of input by community staff. This will be monitored closely and levels of clinician input will be adjusted accordingly.

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Figure 4: Risk groups

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6. Operating Hours for Functions

Figure 5: Overview of operating times within each function

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7. The Seven Functions of Care in More Detail

Community care will be grouped around seven (7) functions as outlined above. This section presents a summary of each function. Significant further detail can be found in the appendices including internal management and reporting structures, exact staff numbers calculated to be required, KPIs, interrelationships with whole-system pathways and much more detailed justification of the reasons behind the systems and processes.

1) Access & Triage This function describes the systems by which all stakeholders will access community health and social services and how these requests for assistance are responded to.

For health the calls for assistance will be triaged by Harmoni (who currently provide the call-handling for 111 and SPoC) then transferred to an Access and Co-ordination hub within each locality. This Access and Co-ordination hub will be staffed by co-ordinators who will have intimate knowledge of services and functions within their locality and be able to access the care needed directly with the appropriate staff.

For Social Services the current call-handling systems will remain the same.

Figure 6: Community Adult Health Services: Health

KPIs will monitor time to call answering, number of dropped calls and numbers of calls reaching a satisfactory destination/conclusion

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Figure 7: Community Adult Health Services: Social Care – located in Wandsworth Social Services

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2) Rapid Response This function is designed to deliver rapid multi-disciplinary assessment and treatment within 2 hours for urgent health needs or breakdown of care within a patient/service user’s own home or nursing home. The staff from this function will also provide IV antibiotics at home where possible. It is intended to be primarily delivered by Advanced Nurse Practitioners or Physician’s Assistants who will also be ‘trusted assessors’ and able to provide defined packages of social care. They will be supported clinically by the Community Services GP and administratively by the Co-ordination staff in the Access and Co-ordination hub within their own locality. Patients/service users with need for ongoing care will be transferred to other functions ( eg. scheduled and ongoing care, complex case management or specialist care) once the acute need has been stabilised. It is intended that this function will have a 5 day limit. The Rapid Response staff will be ring-fenced to ensure there is always capacity and are not subsumed by ongoing care tasks. Figure 8: Rapid Response Pathway for Locality Teams

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Key Performance Indicators:

3) Facilitated and Supported Discharge

FUNCTION PROCESS INDICATORS IMPACT INDICATORS OUTCOME INDICATORS BENEFITS

RAPID

RESPONS

E

Length of time from access

point receipt of referral to

locality team receipt of referral

(The provider will be required

to produce evidence of the

following: 1) The time the call

was received by Harmoni, 2)

The time the referral is

received by the Community

Adult Health Services

Coordinator and 3) The time

of arrival of the ANP at the

patients residence)

SF12 Increased ability to share information

SF07 Increased proportion of care closer to home

SF01 Improved effectiveness of intervention

Proportion of patient/service

users seen within 2 hours of

receipt of referral

Total number of referrals

received, including a

breakdown of onward

referrals made to: locality

teams, specialist teams,

primary care, secondary

care. Quarterly

Proportion of

patient/service users who

have an A&E attendance

within 72 hours of the

referral. (This will need to

be broken down into the

following: 1) one day, 2)

two days, 3) three days)

SF10 Increased access to services

IO03 Reduced acuity of crises

SF08 Reduced assessment delay

Proportion of patients whose

care package is successfully

activated within 6 hours of

receipt of referral (and within

4 hours of clinician seeing

patient)

Proportion of

patients/service users

maintained at home within

24 hours of the referral.



SF07 Increased proportion of care closer to

home

Number of patients/service

users reassessed by RR team

within 24 hours of referral. The

provider will be required to

break the reassessment down

into the following:

1)telephone/review,

2)visit/review.

Proportion of

patient/service users

maintained at home within

72 hours of the referral

Reduction in percentage

of overnight admissions


IO03 Reduced acuity of crises


SF04 Reduced delay for services &

equipment

Proportion of care

packages reduced after

72 hours

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This function will ensure that facilities and support are always available in the patient’s own home (or nursing home) so that discharge from hospital can occur as soon as possible and at a time appropriate to the patient/service user and their families. Teams will be located both in the acute hospitals and in each community locality so that there is seamless co-ordination of plans. The core staff for this function will be ANPs or Physician Assistants, Physiotherapists and Social workers who will liaise directly with the hospital’s discharge teams to ensure smooth and safe discharges into the community.

Figure 9: Hospital Discharge and Community Discharge Teams Pathway

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4) Maximising Independence Maximising independence for people wherever possible is expected to be an overarching ethos throughout community adult health services. Every professional should be considering how their involvement is enabling a patient/service user to live as independent life as possible. The Maximising Independence function is where the responsibility to provide and support rehabilitation and reablement lies. It is primarily led by physiotherapists and occupational therapists and continually bridges health and social care boundaries. It also involves teams that are outside the direct scope of this redesign for various management/funding reason - such as the Integrated Falls Team, the Neurorehabilitation Team and the Early supported discharge for Stroke Patients pathway.

FUNCTION PROCESS INDICATORS IMPACT INDICATORS OUTCOME INDICATORS

BENEFITS

FACILITATED AND SUPPORTED DISCHARGE

Number of patient/service users identified and assessed by discharge team on day 1,2,3,4 of admission, predominantly located on MAU, Senior Health and Medicine wards.

Proportion of discharges that occur on the weekend

Reduction in length of stay for specific conditions

SF04 Reduced delay for services & equipment SF06 Improved effectiveness of discharge IO03 Reduced acuity of crises

The number of patients readmitted during the first two weeks post discharge.

Proportion of failed discharges occurring within two weeks

Reduction in the number of readmissions to hospital, two weeks post discharge

IC02 Increased proportion of need met at home

Number of patients/service users whose discharge is facilitated by the hospital discharge team

Proportion of people requiring continuing care funding

Reduction in referrals for ongoing care to social services

SF06 Improved effectiveness of discharge SF10 Increased access to services

Proportion of patient/service users not supported home who have a follow up phone call within one week of discharge

Proportion of people who are still at home 91 days after discharge from hospital

PC11 Improved service user communication skills PC08 Improved case management skills

Proportion of patient/service users assessed at 2 weeks for ongoing care needs

Proportion of elective discharges that are followed by emergency readmission within 30 days

SF06 Improved effectiveness of discharge IC02 Increased proportion of need met at home

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Figure 10: Maximising Independence Pathway

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5) Complex Case Management This function delivers a truly multi-disciplinary platform to deliver home based care for those patients identified as most vulnerable. This function was inspired by the Community Ward and the Intermediate Care team but intends to deliver a more consistent and co-ordinated service to a wider range of patients that has been possible previously. The patient/service user’s care will be overseen by a Case Manager and their care will be delivered and overseen by a core team of a Community Services GP, Community Matron, Community Services Pharmacist and Dietitian. Social Workers will be part of the core team where the care needs are likely to last longer than 6 weeks.

FUNCTION PROCESS INDICATORS IMPACT INDICATORS OUTCOME INDICATORS BENEFITS

MAXIMISING INDEPENDENCE

Proportion of patients assessed as having reablement/rehabilitation potential

Proportion of people assessed as having no ongoing need following a period of care by the maximising independence function

Proportion of people living at home 91 days after a period of reablement.

IC02 Increased proportion of need met at home IC05 Improved support for care plans

Proportion of people assessed as having a reduction in their level of need following a period of care by the maximising independence function

Reduction in permanent admissions to residential and nursing care homes

IC01 Increased independent living IC05 Improved support for care plans SF08 Reduced assessment delay

Proportion of people assessed as having the same level of need following a period of care by the maximising independence function

Reduction in unscheduled admissions for people as a result of a fall

SF08 Reduced assessment delay IC03 Reduced impairment IC01 Increased independent living

Proportion of people assessed as having an increased level of need following a period of care by the maximising independence function

Proportion of readmissions within 30 days of discharge

SF08 Reduced assessment delay IC03 Reduced impairment IC01 Increased independent living

Number of people assessed by a care champion

Proportion of people assessed as having reached their identified goals.

Reduction in average length of stay for emergency admissions

PC09 Increased patient facing time PC06 Increased service user participation

Number of people with a goal orientated care plan agreed with their care champion

Reduction in fractured neck of femur

IC04 Increased number living their care plans IC03 Reduced impairment

Proportion of people feeling supported to manage their condition

PC06 Increased service user participation PC10 Improved surveillance skills

Proportion of people at risk of falls who report an improved quality of life

PC06 Increased service user participation IC01 Increased independent living

Proportion of people at risk of falls who report a reduction in fear of falling

PC06 Increased service user participation

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Patient/service users will be identified from predictive risk modelling, and health professional assessment both within and without community adult health services (eg secondary and primary care). It will be this function that provides the main platform for community adult health services interfacing and working with Community Geriatricians, Palliative Care Teams, Voluntary Sector and Care agencies. It will be these patients/service users who will form the bulk of the discussions at the weekly MDT meetings. Figure 11: Complex Case Management Pathway

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6) Scheduled & Ongoing Care This function incorporates all the ongoing care needs that have traditionally been provided by community nursing staff in conjunction with the patient/service user’s registered general practitioner. In the new model the community nursing staff will have the added support of the administration capacity within the access and co-ordination hub and ready access to senior clinical experience within each locality ie Community Services GPs, community matrons, ANPs, social workers, community services pharmacists and more.

FUNCTION PROCESS INDICATORS IMPACT INDICATORS OUTCOME INDICATORS

BENEFITS

COMPLEX CASE MANAGEMENT

Daily ward rounds take place in each locality

SF12 Increased ability to share information PC03 Increased multi-disciplinary team working

Proportion of patients identified by the risk stratification tool who are assessed by the complex case management function

Reduction in the number of GP appointments (planned and home visits)

Reduction in the number of A&E attendances

SF11 Increased anticipatory care IC02 Increased proportion of need met at home

Proportion of people in the function who have a named case manager

Reduction in the intensity of care package received at home

Increase in the average age of person permanently admitted to residential and nursing care homes

PC07 Increased no. of accountable care workers IC02 Increased proportion of need met at home IC01 Increased independent living

Proportion of people that have a crisis action plan

Reduction in the number of patients recorded as permanently admitted to residential and nursing care homes

SF03 Increased number of care plans IC01 Increased independent living

Proportion of care plans are reviewed every month at a multidisciplinary team meeting

SF12 Increased ability to share information PC03 Increased multi-disciplinary team working

Number of safeguarding alerts completed in reporting period

PC04 Increased no. trained to meet cohort needs

Proportion of patients who have undertaken a medication usage review

SF11 Increased anticipatory care

Proportion of carers assessed and supported

The proportion of carers who report that they have been included or consulted in discussion about the person they care for

PC05 Increased referrals into services by carers

Proportion of patients given information on self-management

Proportion of people feeling supported to manage their condition

PC06 Increased service user participation

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Figure 12: Scheduled and Ongoing Care Pathway

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7) Specialist Input There is the ongoing need for specialist skills in community adult health services to deliver effective care for specific conditions. It is anticipated however that wherever possible specialist staff will understand that they are expected to provide care across and outside their specialties wherever the patient/service user needs demand it and it is practically possible. Some specialist teams such as mental health and drug and alcohol services are outside the scope of this redesign but it is intended that they seamlessly work with community adult health services and make use of the access and co-ordination hubs wherever possible to deliver the best care for patients. Their specialist skills are essential in providing the best care for a very significant proportion of community and social services patients/service users. The need for integration and seamless working with Community Mental Health Workers cannot be overstated. It is an essential feature of on-going implementation. Specialist Nurses will be employed in sufficient numbers to support patient/service user care in their own homes:

Diabetes Specialist Nurses

Specialist Heart Failure Nurses

Respiratory Nurse Specialists

Specialist Tissue Viability Nurses

Specialist Continence Nurse

Dementia Nurse Specialists Psychological Support will be provided as part of the locality team to deliver therapeutic intervention within people’s own homes where needed to support patients/service users with their health and social care needs.

SCHEDULED ON-GOING CARE NEEDS

Proportion of patients referred for ongoing education or management of their long term condition

Proportion of patients who feel supported to manage their condition

PC06 Increased service user participation IC04 Increased number living their care plans

Proportion of people who use services that have control over their daily life

IC01 Increased independent living

Proportion of terminally ill patients who achieved their preferred place of death

Proportion of patients who place of death was consistent with their documented place of choice

IC04 Increased number living their care plans

Proportion of patients that have a long term care plan that was shared with them and agreed

SF03 Increased number of care plans IC01 Increased independent living

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8. Services Aligned with the Functions

1) End of Life Care The need to deliver effective end of life care in people’s own homes wherever possible is taken as read. The EoLC services in Wandsworth will be fully integrated within this community adult health services redesign.

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Figure 13: EoLC Patient Family and Carer Needs

2) Telehealth & Telecare Telehealth Kits are commissioned by WCCG and will be used in patients whose condition is likely to benefit from its application. The findings will be monitored centrally by the commissioned provider of Telehealth services and the information will be fed back to Community adult health services via the access and co-ordination locality hub to be acted on appropriately.

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Telecare is range of kit commissioned by Social Services and is used to provide continuous, automatic monitoring of service users who are vulnerable to things like falls, floods, fire or gas leaks. This greatly enhances service user’s ability to live independently.

9. Out of Hours Provision – across all functions

This function is of course essential to provide a 24/7 service. GP services will be provided by Harmoni according to their contract. There will be a much improved transmission of information about vulnerable patients/service users between community adult health services and out of hours services. Nursing staff within the Scheduled and Ongoing care function within community adult health services will be available on a 24/7 basis in a shift pattern appropriately adjusted according to patient/service user care needs. Social Services Emergency Duty Team operate an out of hours service to support the scheduled and ongoing care function.

10. Information Technology

EMIS Web is the computer system the provider will be expected to use for Community Adult Health Services. For our patients/service users to receive co-ordinated, seamless care it is essential to have computer systems that are accessible to all staff involved in their care. It is also imperative that computer systems used by community adult health services operate interactively with systems used by other providers within the whole system including primary care, secondary care and social services. There are no existing perfect systems on the market but the platform that has been identified as having the best chance of integrating synergistically is EMIS web as this system is already in use by all of Wandsworth General Practices and has an effective Community Services platform. The provider will be expected to have Community adult health services using EMIS web as soon as practical and will be expected to work with commissioners to ensure that secondary care and social services data are integrated and accessible as soon as possible. Responsible and robust Information Governance issues will be of paramount importance in the use of computer systems. Mobile devices/technology will be utilised throughout community and social services and these will be funded by commissioners but maintained by providers. Further significant detail regarding IT is to be found in the appendices.

11. Estates

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Having the appropriate buildings to work out of is fundamental to the effective provision of community and social services. These issues have been thoroughly researched and the costs estimated. The provider will be expected to support the recommendations. Figure 14: Indicative Estates Required for the Delivery of the Functions

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12. Further Expectations of Provider

Safeguarding Vulnerable Adults It is essential that this is regarded as ‘everyone’s business’ throughout health and social services. The provider will be required to have a robust process is in place to ensure this is central to every intervention.

Staff Employed by Provider The provider will ensure that all staff employed are suitably vetted and qualified to perform their roles within each function.

Risk Management Appropriate risk management must be resourced, delivered and monitored.

Infection Prevention All staff will be required to use appropriate infection prevention procedures and the provider will need to demonstrate appropriate training and monitoring of this.

Complaints Robust and responsive systems to deal with complaints must be in place.

13. Conclusion

Redesigning the way our population is cared for by our health and social services is essential. We can no longer afford to provide care that is designed for the benefit of the service rather than the service user. Providing a platform for specialist secondary care expertise and mental health services to access the community adult health services and enabling community expertise to reach into secondary care is essential if our population are going to stay healthy and independent at home. All elements of this redesign started with people’s needs and expectation. It was filtered through the knowledge of staff working within these services and captured their ambition to provide a better service for their patients/service users. Its ideas and theories have been researched thoroughly and tested extensively with a combination of fresh-faced enthusiastic staff and vastly experienced managers and clinicians. This document describes the starting point of an exciting transformational journey. It allows for robust systems by which solutions to unforeseen challenges can be dealt with by commissioners and providers pragmatically and safely. Determined monitoring and responsible financial governance will be vital. Ambition, creativity, courage and determination are needed from commissioners and providers.

wandsworth community adult health services specification · 2013. 10. 9. · older people –...

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