Published on March 11, 2014
Initial Response Team & Principal Community Pathways Anthony Deery Nurse Director Urgent Care 26th February 2014
Northumberland, Tyne and Wear NHS Foundation Trust • Population of 1.4 million people in the North East of England • Six geographical areas of Northumberland, Newcastle, North Tyneside, South Tyneside, Gateshead and Sunderland • One of the largest mental health and disability organisations in the country • Income of circa £300 million and circa 6,000 staff • Over 130 sites and provide a range of comprehensive services including regional and national specialist services
Initial Response Team South of Tyne and Wear REQUEST FOR HELP ROUTING ST UCT OPS LD ICTS SL UCT OPS LD ICTS GH UCT OPS LD ICTS Home Based Treatment Assessment Gatekeeping Home Based Treatment Assessment Gatekeeping Home Based Treatment Assessment Gatekeeping Information Collection, Triage & Routing 11 Gateshead Rapid Response Nurses 11 South Tyneside Rapid Response Nurses 11 Sunderland Rapid Response Nurses South of Tyne and Wear Model
Service User Experience Carer Feedback GP Feedback Wonderful support! Brilliant team! Fantastic – a huge improvement!! You should have done it before Staff Feedback More manageable Skills are valued A lot happier Spend more time Yes No Did the Initial Response Team meet your needs? The Team were excellent keep this very valuable service going Service Feedback and Evaluation of Pilot
Principal Community Pathways A programme to design and implement new, evidence-based community pathways for adults and older people. Our ambition is high and is matched by the expectations of service users and carers. The new pathways will: • Significantly improve quality for the patient • Double current productive time of community services by redesigning current systems • Enhance the skills of our workforce • Improve ways of working and interfaces with partners • Reduce reliance on inpatient beds and enable cost savings This is not achievable in isolation and to be successful we need it to be part of integrated work with partners
The symbiotic relationship PCP and Bed Model Better Community Reduced Beds Money available Virtuous Circle Make savings £ £ Fewer inpatients Reduced cost Poorer community More beds than realised Less Money available Vicious Circle Make savings -£ Not as few inpatients More cost than realised£
Design Workshop Workshop Product Specification Scope Boundaries Principles Benefits People Constraints Reasonable adjustment for pathway Check Does this meet the Product Specification? Sign off Ready to test Design and Standard Work #1 Design and Standard Work #2 Gather data Invite people Refine Week 0 Week 6 Week 7 Week 8 Check Does this reflect previous discussion and principles? The design workshop process
Principal Community Pathways – How people have been involved So far 362 people have attended the 27 clinical and supporting systems workshops, these have included: GPs, Local Authority staff, Acute Trust staff, Community and voluntary sector staff, CCG staff, NTW staff and most importantly our service users and carers. • Our Trust-wide Service User and Carer Reference Group has been involved throughout • We have presented our plans to various groups including HealthNet and South Tyneside GP Education Forum • We’ve been ‘walking the wall’ with all of our stakeholders and have so far run sessions for over 800 people – with more to follow
Benefits of PCP Service Users and Carers CCGsWorkforce Partners • Quicker, easier access • Recovery focused, collaborative care • Enhanced packages of care • Alignment of care across partners • More efficient, safer systems • Integrated care • No ‘bouncing’ • More time spent with service users • Clear roles and responsibilities • Increased job satisfaction • Enhanced skills • Improved communication and information sharing • Reduced duplication
Patient Process step Carers Access Assessment Treatment Discharge 24 hour access Contact within 24hrs and offered choice of venue and appointment time Self referrals No waiting lists Quicker re-engagement when needed Able to make referrals Can ring for advice and support with or without a referral More informed, clearer plan Within 7 days of referral receipt Given information to help prepare Text message or phone call reminder Greeted by front of house staff where clinic appointment needed Full baseline physical health check where required Can be involved if appropriate Common sense confidentiality Assessments for carers Text message or phone call reminders for appointments Patients receive treatment in line with NICE guidance Peer Support Workers and community workers to help with social issues Treatment and care in the most suitable environment Care plans developed collaboratively Can be involved if appropriate in treatment planning and delivery Can request a review at anytime and help with decision making Carer involved in discharge planning and have their own plan Re-engagement process available if needed Discharge process is considered from beginning of assessment helping to prepare for discharge Discharge plan includes how to ‘stay well’ and what steps they should take in the event of a relapse
Process step GP & Partners Referral Assessment Treatment Discharge A single point of access for urgent or non urgent referrals using telephone, email, fax or letter 24/7 A copy of the assessment documentation within 48 hours Where medication changes are required clear guidance and communication will be provided Clear and concise updates and action plans A clear and concise discharge summary If relapse occurs a simple referral route back into services Social Services A single point of access for urgent or non urgent referrals Co-ordinated discharge process involving all professionals Part of review process as appropriate Joint treatment planning Holistic view of service users needs Opportunity for joint assessments where indicated Shared information across organisations Advice Line Advice Line
Process step Referral Assessment Treatment Discharge Community Staff Inpatient Services Specialist Services Co-workingLink worker Specialist service provides a FAQ factsheet and online presentation to reduce repetitive requests for the same advice Earlier consultation for advice Provision of scaffolding Estimate less usage as staff get skilled up in core services Quick access to community services to enable transitions from other services Continued involvement from the community team – in reach model, resulting in less need for inpatient therapies Timely discharge from inpatients Clearer plan and responsibilities Quick referral and allocation of a worker Reduced need for inpatient beds Discharge will involve all relevant health professionals and partners Positive attitude to risk management and safety planning Social needs addressed sooner Based on workload not caseload Clear guidance on treatment that should be provided Will match skill set and train staff when needed Quick access to advice from specialist services Preparation time booked in assessors diary Where possible the assessor will provide treatment Documentation reviewed so that assessment flows better Streamlined approach to external and internal referrals Open referral system where we can ask more questions from the referrer / service user/ carer More responsive IT systems and less paperwork Access service will gather as much information as possible before the assessment
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