iCares Sandwell

Integrated Care Services (iCares) @icares_SWBH iCares -­‐ 7 days a week, 8am – 8pm • 
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Long term condi-ons / adults Case management is everyone’s business Community Rehabilita-on is everyone’s business Open access for life Respond according to pa-ents clinical need irrespec-ve of diagnosis or loca-on 3 hours – admission avoidance 72 hours – care management <15 days – rehabilitaEon / reablement Self care & self management Case for Change -­‐ The challenge Cost saving every year 60% increase in demand (DH QIPP) Demand increasingly complex Customer sa-sfac-on (client & commissioner) Quality & Safety • Numerous Teams • 5 points of access • 8+ bases for staff • Long waits • Handoffs & inter-­‐team referrals • Varia-on across bases • Duplica-on • Part -me admin & answer machines in each base • Mostly 5 days a week • Lots of paper & filing cabinets Users Wanted Something Different •  Service users –  Responsive care –  Right person at the right -me –  Joined up services •  Staff –  Ability to respond –  Easy pathways –  Less admin •  SWBH & GPs –  Reduced admissions –  Reduced length of stay –  Single point of access QIPP LTC: Sir John Oldham, clinical lead •  3 part approach to managing increase in demand –  Risk stra-fica-on –  Integrated locality teams –  Self care Need to implement all 3 together and systema-cally The Evidence Base An integrated locality care team embraces specialist services when necessary, but treats a paEent holisEcally, regardless of their condiEon(s). Thus moving from a biomedical model to a psycho-­‐social medical model (QIPP Handbook). Its all about...................... Only 18% of people with COPD have just COPD Only 14% of people with diabetes have just diabetes Only 5% of pa-ents with demen-a have just demen-a Developing the pathway •  Audits of – 
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Public health data – incidence and prevalence Telephone calls Triage processes Appointment slots offered vs. planned Capacity modelling DNA / missed appointments Response Times WTE, skill mix, bases •  Review of evidence base •  A high level idea: no detail •  Met with GPs, managers, union reps, PCT Its all about...................... Making it easy Reducing hand offs Solu-on focussed care Community as a speciality How did we ensure engagement
UPWARDS, ACROSS AND DOWN •  Conscious communica-on §  Emo-onal §  Theore-cal / Analy-cal §  Policy & Process Driven •  Varied communica-on styles §  Tell stories §  Newslecers, emails §  Be visible, open door, walk the walk •  Shared the context, the data & the pa-ent voice §  Unions / Leaders / Commissioners / GPs / The staff (via LiA) / Pa-ents •  Honesty & openness. We are not perfect, its OK to say sorry. •  Asked (expected) staff to perform – they will, they know the solu-ons & are more crea-ve •  Fed back praise & recogni-on •  Celebrated the successes & acknowledged the issues •  Focused on the pa-ent outcomes & impact. •  Never gave up 5 months engagement Listening into Ac-on event (LiA) Func-on before form Working par-es Pathway development Scoping & borrowing / Benchmarking •  Market place event •  Op-ons appraisal re form •  Process development • 
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ConsultaEon •  Formal management of change •  Unions welcomed •  Open door •  Leadership skills •  No name yet •  Start date – no going back •  Everyone changed role, base, line manager, hours of work Its simple Urgent Specialist Decision Rou-ne Self Management Triage Contact Centre It’s joined up Urgent • 
We will see you urgently to stop your condi-on gehng worse and where it is safe to avoid an admission to hospital Specialist • 
We will help you to see a specialist to work with you to; •  understand your condi-on •  manage your condi-on becer •  get treatment for your condi-on RouEne • 
We will provide treatment to help you get becer and live life as well as possible Self-­‐Care • 
We will help you to understand your condi-on and what you can do to help yourself Services / funcEons delivered by iCares Rapid Response Doms AA Clinic / PCAT OPAT DVT Bridging the Gap Community Offer PrevenEon OBI / IMC Care Management CNSs Care Homes team Specialists within locality teams Reablement RehabilitaEon incl. stroke, falls, neuro, TBI, frailty PalliaEve Rehab Rehab Unit (DH) It flows Risk strat. LACE Urgent , AA, PCAT Intermediate Care ROGS– The Integrated delivery model Red = unplanned care, urgent response required. Home, clinic or hospital Self Management Case Management, Specialist Orange = complex and/or unpredictable. Will need a specialist to assess, diagnosis and prescribe a treatment package i.e. case management Green = planned care, rou-ne. Clinic or home Self care = what each of us can do to live well and enjoy life. Home and community ac-vi-es Long Term Rehab, planned care, groups, Rehab Unit (DH) RouEne, Planned OBI, intensive intervenEon Services / funcEons under one umbrella Admission Avoidance RehabilitaEon Doms Reablement with social LTC Management care & EAB PCAT / Clinic Intermediate Care CNSs – progressive neuro IV Therapy Community Rehab Frailty OBI Neuro – stroke, TBI, Bone Health DVT Falls Care Homes Team Pallia-ve rehab Rowley Rehab Unit (DH) Case Management Workforce -­‐ Headcount Registered Staff Non Registered Staff 73 74% 26 26% Therapists Nurses 43 30 59% 41% Delivered by Community Matrons, Clinical Nurse Specialists Therapists – PT / OT / SLT Psychologists Assistant Prac--oners, Support Workers, Home Accident Preven-on Team Admin hubs Clinical Team Leaders Outputs / KPIs
Responsiveness ü  Wait for rehab and reablement dropped from 40 days to an average of 16 days ü  Bed occupancy has increased from 85% -­‐ 93% ü  LOS in Own Bed Instead 24 days (standard 29 days) ü  92% of pa-ents return home from nursing home based IMC beds in under 6 weeks ü  2% reduc-on in readmissions via LACE Pa-ent experience ü  93% of pa-ents would recommend the service to their friends and family ü  77% of pa-ent set rehab goals are achieved with 100% success (90% full and part achieved) ü  93% of AA Doms referrals avoid admission to acute Staff tell us…… “Autonomous working” “Variety of caseload in community” “Holis-c working” “Give them (pa-ents) our all” “Opinions are valued” “Leaders seem to care” Your Voice – Trust Staff Survey
Trust wide survey, via email quarterly. It is anonymous.
Yes / no questions as well as free text.
Receive all the comments as well as graphs and tables
based on responses.
Doesn't replace any of the comms or leadership
strategies described earlier. Its another tool.
Directorate Total Responses Response Rate Disengaged Neutral Engaged iCares Directorate District Nursing 93 31% 15% 4% 4% 31% 26% 65% 70% Community Respiratory 80% 1% 31% 68% Rehab (iCares) Service 40% 3% 33% 63% Users tell us……… “You hear about going the extra mile, they went an extra 200 miles” “Don’t know where we would be without you” “Every goal I wanted to achieve I achieved” “Pat yourselves on the back, you are the best thing that ever happened to me” “Like family walking through the door” iCares Directorate Overview PEQ results Q1 -­‐ Q3 (2015/16)
Out of 1351 responses 1295 patients
said they know who to contact between
appointments
T Returns 1416 56 Yes 1295 No Likely to recommend 97.32% iCares PEQ results 100% 99.65% 99.79% 99.71% 99.86% 98.93% 96.90% 90% 80% 70% 60% 50% 40% Yes 30% No 20% 10% 0% 0.35% 0.21% 0.29% 0.14% 3.10% Were you Do you feel you Do you feel staff Do you feel staff Were you
had the
satisfied with
have been
delivered your involved in the
knowledge and treatment with decisions made
the standard of
treated
care received? respectfully? skills required to confidence? regarding your
deliver your
treatment?
care?
1.07% Did you have
enough time
and opportunity
to discuss your
care &
treatment?
Total referrals to iCares No. Referrals 14000 12000 10000 8000 6000 4000 2000 0 Red Stream Green Stream 1112 1680 8812 1213 1984 9772 iCares is born. NB reconfig. skewing stats 1314 2106 8780 1415 3028 9632 1516 4870 8242 Drop in green stream All Admission Avoidance Referrals
900 800 700 600 500 400 300 200 100 0 PCAT Referrals iCares AA Doms LACE – Re-­‐admissions •  Automa-cally generated IT tool to help reduce re-­‐admissions •  Scoring system to iden-fy pa-ents at high risk of re-­‐ admission •  Electronic bed management system (eBMS) scores against a criteria Length of Stay Acuity of admission Case Mix of the pa-ent Number of ED acendance in the past 6 months •  Scores are weighted and only pa-ents with a score of > 11 will general a symbol on eBMS LACE – Re-­‐admissions •  Discharge checklist is generated on ward •  Checklist forms the basis of a conversa-on with pa-ent and or carer •  MDT discussion during board rounds prior to discharge •  Community Team pick up pa-ents discharged from wards the previous day with a LACE score of > 11 •  Ward entries and discharge summaries reviewed before ringing pa-ent LACE -­‐ 4 Months snapshot – 174 Pa9ents reviewed (Feb 2016) Urgent visit-­‐ 4 hours High Priority -­‐ 72 hours Rou-ne visit with 15 days Discussed & No further ac-on Urgent visit-­‐ 4 hours, 8, 5% High Priority -­‐ 72 hours, 25, 14% Other, 28, 16% Rou-ne visit within 15 days, 14, 8% Discussed & No further ac-on, 99, 57% Outcomes
Measure Standard/Benchmark Performance LOS OBI 29 days 24 days Rou-ne Response Times 40 days 16 days DVT Ax per Year 750 738 Care Homes admissions Sustaining the change Workforce are the key to momentum •  Co-­‐loca-on •  No professional leads •  Permission to find solu-ons –  Do what’s right for the pa-ent •  Specialists vs. generalists debate •  Tenacity •  Resilience Learning
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Focus on outcomes & commissioning Use the evidence base Cant communicate too much Ask for help The teams know the answers Tolerance of difference There is nothing to hide The theorists need to know why The reflectors need to reflect The power of the data & pa-ent stories to keep the momentum going Why do we think it works? – Top Tips •  The ability to respond according to clinical need rather than loca-on, age or diagnosis •  The breadth of its reach -­‐ from pre-­‐diagnosis to death •  Case Management is everyone’s business •  Community RehabilitaEon is everyone’s business •  Depth of exper-se held by co-­‐located nurses, therapists & other professionals who together are able to do what’s right for the pa-ent -­‐ Building Rela-onship's ↑ increasing respect Thank You sandwell.icares@nhs.net Sandra Kennelly 0121 507 2664 (opEon 5)
@icares_SWBH