Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
1
Cluster Network Action Plan 2015-16
Afan Cluster
2
The Cluster Network1 Development Domain supports GP Practices to work to collaborate to:
• Understand local health needs and priorities. • Develop an agreed Cluster Network Action Plan linked to elements of the individual Practice Development Plans. • Work with partners to improve the coordination of care and the integration of health and social care. • Work with local communities and networks to reduce health inequalities.
The Cluster Network Action Plan should be a simple, dynamic document. The Cluster Network Action Plan should include: -
Objectives that can be delivered independently by the network to improve patient care and to ensure the sustainability and modernisation of services.
Objectives for delivery through partnership working
Issues for discussion with the Health Board For each objective there should be specific, measureable actions with a clear timescale for delivery. Cluster Action Plans should compliment individual Practice Development Plans, tackling issues that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered through collaborative action. This approach should support greater consistency of service provision and improved quality of care, whilst more effectively managing the impact of increasing demand set against financial and workforce challenges. The action plan may be grouped according to a number of strategic aims.
1
A GP cluster network is defined as a cluster or group of GP practices within the Local Health Board’s area of operation as previously designated for QOF QP
purposes
3
Strategic Aim 1: To understand the needs of the population served by the Cluster Network
No Objective Key partners For completion by: - Outcome for patients Progress to date RAG Rating
1 Deliver testing/monitoring/screening/lifestyle on an annual basis to all those with Pre diabetes or at risk of Pre-diabetes
Afan Cluster Lead GP: Dr Mark Goodwin
3 year rolling programme in first instance
Lifestyle advice and support for patients to delay onset of diabetes
All practices have started to provide advice. Waiting for the delivery of agreed leaflet October 2015 – 2 practices have hit 90%. 3 have not started. Small practices are doing very well
Amber
2 To strengthen GP multi-disciplinary team engagement with other stakeholders in community networks and other service users via QOF levers
Individual Practices/Patients/LHB/LA
March 2016 Provision of co-ordinated holistic care; reduced duplication
October 2015 – some practices have carried out MDT practices
Amber
3 Improve patient and carer engagement to maximise benefit from reviews as required in QOF, enabling the patient to have the opportunity to feedback
Individual Practices/patients
March 2016 Red
4
to the development of priorities through a PPG or other formal/informal feedback (CND001W)
4 Increase flu immunisation uptake in general practice
PHW Lead GP: Dr Mark Goodwin
March 2016 Protect patients at risk and the wider population
October 2015 Dr Mark
Goodwin agreed to
become flu champion to
support practices identify
a flu champion, share flu
uptake information with
the cluster, share
resources, and identify
and share best practice.
Green
5
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable
needs of local patients
No Objective Key partners
For completion by: -
Outcome for patients Progress to Date RAG Rating
1 To develop a generic
solution for communication
to and from locum GPs and
secondary care
Afan Cluster/LHB Lead GP: Dr H Browning PM Lead: Paul Carmichael
March 2016 Improved continuity of care/reduced risk/ streamlined consistent processes
October 2015 – lead GP and PM identified
Red
2 To reduce pressures in
primary care:
1. To collect examples of
inappropriate work passed
to primary care from
secondary care and Care
Homes:
Requests for
expedited referrals:
Patients told to
contact GP for
expedite letter.
Change of
Afan Cluster
Lead GP: Dr
Kristy Mellin
Lead PM:
Katie Harris
March 2016 Improved access to primary and secondary care services/diagnostics; less avoidable delay; more timely intervention to medical care
October 2015 –Lead GP
and PM identified
Red
6
management by
OPD – First
prescription to be
issued by OPD
(specifically mental health)
Delayed, illegible and incomplete discharge summaries
Requests to
prescribe medication
following hospital
discharge: Patients
should be given
interim prescription
on discharge
3 To provide accredited training for prescribing clerks
Medicines Management Team
Lead PM: Rachel Griffiths/Phillipa Thomas
Lead GP: Dr Richard
March 2016 Improved repeat prescribing systems
Training packs in development
Amber
7
Penney
Strategic Aim 3: Planned Care- to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms
No Objective Key partners
For completion by: - Outcome for patients Progress to Date RAG Rating
1. Implement a case management approach to co-ordinate the care of the most frail in the community, as one of the early adopter sites
Afan Cluster/LHB/LA Lead Manager: Paula Heycock
Co-ordinated approach to care; timely access to appropriate services; reduced unplanned admissions
Implemented in Kings Surgery; further practices in the Afan valley identified as next cohort Progress October 2015: Cymmer and Afan Valley practices in discussion as next phase
Green
8
Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the
continuous development of services to improve patient experience, coordination of care and the effectiveness of risk
management
No Objective Key partners
For completion by: - Outcome for patients Progress to Date RAG Rating
1 To improve antimicrobial stewardship
Medicines Management Team
Ongoing quarterly monitoring of trends
Reduced resistance
Reduced C.Diff
Increased knowledge and empowerment to self care
Discussed at all annual practice prescribing visits. Cluster level data to be shared at forthcoming cluster meeting
Amber
9
Strategic Aim 5: Improving the delivery of end of life care
No Objective Key partners
For completion by: - Outcome for patients Progress to Date RAG Rating
1 Feed any safety concerns into the palliative care service regarding use of Just in Case box scheme where appropriate
Afan Cluster Lead GP: Dr Steve Rohman?
Timely, appropriate access to medication
October 2015- Review of Just in Case Scheme completed. Cluster to feed adhoc safety issues.
Red
2 To Improve communication with OOH services for patients considered at end of life
Afan Cluster March 2016 Better continuity of care between providers
Time limited LES launched November 2015. Participating practices to respond by December 11th 2015
Green
3 To take part in the QOF requirements for improving end of life care (CND 007W): - Using SEA to
assess delivery of end of life care
- Identify any learning and
Individual Practices/Afan Cluster
March 2016 Improved end of life care For review in January/February meeting
Amber
10
actions - Summarise
themes for discussion at cluster meetings through use of proforma
Strategic Aim 6: Targeting the prevention and early detection of cancers
No Objective Key partners
For completion by: - Outcome for patients Progress to Date RAG Rating
1 To liaise with Radiology to develop and follow
pathway for acting on abnormal chest X-ray
Afan Cluster/LHB Lead GP: Dr Pat Wong – Primary Care Executive Board
March 2016 Consistent and timely access to diagnostics
October 2015 – taken forward by Primary Care Executive Board with support from Cluster as appropriate
Amber
2 Complete and review significant events
relating to patients who have been
referred from one hospital speciality to another, with the GP
being asked to make that referral, which
Afan Cluster Lead PM: Deborah Picton
More timely access to treatment/diagnostics
October 2015 – Lead PM identified. LMC collecting similar information
Red
11
places an unnecessary
step in the diagnostic process
3 To take part in the QOF National Priority Areas (CND 006W):
- Reviewing the care of all newly diagnosed lung , digestive and ovarian cancers
- Summarising learning and sharing actions
- Completion of proforma for discussion at cluster meetings
Afan Cluster March 2016 Improved cancer care and early diagnosis and treatment
For review in January/February meeting
Red
12
Strategic Aim 7: Minimising the risk of poly-pharmacy
No Objective Key partners For completion by: - Outcome for patients Progress to Date RAG Rating
1 Review how practices can work together to organise themselves to streamline general medical services for patients in care homes
Afan Cluster Lead GP: Dr Kevin Hunt
Improved safety and quality and access to GP services
October 2015 – Lead GP identified. To look at feasibility of 1 practice per care home, Dr Hunt to hold discussions with care home and feedback to the cluster
Red
3 To provide accredited training for prescribing clerks
LHB Medicines Management Team
March 2016 Improved repeat prescribing systems
October 2015 - Training packs in development
Amber
4 To engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes (which contain polypharmacy elements)
LHB Medicines Management Team
PMS 15/16 – by March 16
PMS + respiratory – by November 16
Improved medicines management including polypharmacy
All practices engaged and making progress
Green
5 To take part in the QOF requirements to minimise the harms of polypharmacy (CND 008W)
- Identify patients in the cohort
- Undertake
Afan Cluster March 2016 Improved prescribing and medicines management
For review in January/February meetings
Red
13
face to face medication reviews
- Identify actions for learning
- Summarise themes for sharing with the cluster
6 To explore the possibility of polypharmacy reviews in the early adopter group of patients
Medicines Management Team
Ongoing Improved medicines management including polypharmacy
Not yet started Amber
Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance
No Objective Key partners
For completion by: - Outcome for patients Progress to Date RAG Rating
1 To complete the CGPSAT and achieve at least level 2 in the areas of safeguarding (CND 005W)
Afan cluster March 2016 Improved quality and safety and efficiency of services
Amber
2 Encourage use of DATIX by all Practices
Afan cluster/LHB
ongoing Improved quality and safety of services
Green
14
Strategic Aim 9: Other Locality issues
No Objective Key partners
For completion by: - Outcome for patients Progress to Date RAG Rating
1 To input into
solutions to the GP
recruitment crisis,
including options
to offer newly
qualified GPs
incentives to rotate
in different settings
coupled with
educational and
mentoring
Afan cluster/LHB Lead GP: Dr Paul Williams/ Primary Care Executive Board
ongoing Improved/more appropriate access to general medical services
October 2015 - Taken forward on a wider basis by Primary Care Executive Board with support from the cluster as required