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Northumberland Primary and Acute Care Systems
Northumberland, Tyne & Wear & North Durham (NTWND) Sustainability
Transformation Plan and Spread of New Care Models
1st December 2016
STP and New Care Models Spread
Areas of focus• Prevention Health & Wellbeing at scale• Out of hospital collaboration for Health & Social Care• Optimal use of the acute sector• Mental health
STP - delivery vehicle for New Care Models spread Shape and deliver the out-of-hospital model Common enablers
Workforce Local digital roadmaps (Great North Care Record) Estates
Common purpose - Common Vision
‘ONE BED, ONE OUTCOME’
‘Develop a sustainable, high quality New Care Model for people in community-beds and receiving home-based care services across
Gateshead’.
Where we started …
• 206, 000 population• 9% increase in people aged 85 years of age by
2030• Over 1500 beds (community)• By 2020 care home beds = 3098• Cost to health = £3.1m each year• By implementing the New Care Model we expect to
be able to save £4.1m per year (health only)
Long-stay beds (Care-homes)
Short-stay beds(intermediate/reablement
beds)
Home-based care (intermediate / reablement /
domiciliary care)
Care and Support Planning
OUTCOME-BASED CONTRACT + PAYMENTS
CO-COMMISSIONING
PROVIDER ALLIANCE NETWORK
Case Management
INPUTS
Communications Strategy
OUTPUTSActivities Participation
Outcomes - work stream
Care Pathway –work stream
Governance development
Strategic alignment/development/5 year plan/ CCG/LA plan
Engagement/involvement of stakeholders and public and users – work stream
Engagement of CCGs/LA and NHSE, Vanguard National Team/Vanguard 6
A new outcome-based contract and payment model for new service
AssumptionsFragmentation existOutcome contracting will helpFinding, skill, expertise existDevelopment of coordinated care plansPressure to lower A&E attendancesNeed to integrate care better
External FactorsFunding constraints/personnel change/level of participation/national director changes/private market/legal frameworks
Evaluation1. Is the analysis of the problem correct?2. Are resources available and being
used?3. Are we delivering the activities and
agreed standards?4. Are we reaching the right people?
What factors are affecting take up?5. Are we making a difference?
Improvement in comprehensive care
Improvement in coordination of care
Improve access to healthcare within care homes
Improvements in whole, person centred care
OutcomesShort Medium Long
Funding
Vanguard local Team – project management
Vanguard National Team
Resources and support
Care Home 6
Better Care Fund
LTCs and fragility strategy
Readiness to work in partnership
Proactive approach to integrated care
National support
A willingness to improve data sharing across boundaries
NHS England Five Year Forward View
Workforce/training/education – work stream
Evaluation strategy
A new enhanced healthcare service specification (enhanced care pathway) for care home provision
Establishment of a Provider Alliance Network (PAN)
Strengthened engagement/involvement with public –improving trust, self-care, decision-making
Collaborative working across providers –sharing resources, skills, expertise to improve value and up skilling workforce
Standardisation of care delivery – reducing variation, harm, health inequalities etc.
Improved sharing of information –reducing duplication, harm, improved decision-making, access
Key
Funding and efficiency gap
Care and quality
Health and wellbeing gap
Improved quality of life
A sustainable, value based service
Improved patient user experience
Improved provide experience and satisfaction delivering the service
Contract/payment work stream
Perspective
Patient
Professional
System
Local community
Environment Power shift
Avoid silo working
Service setting
Governance
Location
VANGUARD CARE HOME PROGRAMME – LOGIC MODEL
Care Pathway – Areas of Focus
Ward Round : Virtual MDT
Progress
Case Study Example: Sunderland MCP
Out of Hospital Model/ Integrated CareSunderland’s Response to those challenges is an evidence based - Whole System Approach• Community Integrated Teams – Proactive Care
(Wrapping services around patients to deliver a person centred individualised care)
• Recovery At Home – Responsive Care (Intermediate Care / Urgent Care / Social care support / OPAL service )
• Enhanced Primary Care – To focus on patients with morbidity who would benefit from a morestreamlined care in the community
• Digital Solutions / Digital Roadmap• Interface with Urgent and ambulatory
care
The MCP Care Model
Initial Outcomes So Far• 1.78% of adult population have either an EHCP or HSCP• For the YTD, average LOS has decreased substantially
for all age bands, equivalent to 31% across all admissions when compared to the same period in 15/16
• Staff and patient feedback has been extremely positive• Continued reduction in DTOC – Currently one of the
lowest in the country• On track to achieve reduction in admissions by 1,250
admissions/year• Reduction in admissions to care homes• Increased expenditure on community
therapies and packages of care
Tracking of MDT Patients and Impact
Regional Evaluation• Review common themes across each of the North
East vanguards. • Formative and summative in design. • Key themes that the evaluation needs to consider, as
detailed below.
MDT approach
Technology and Digital Solutions
Culture and relationships
Cost benefit analysis
NCM Key Points of mobilisation and spread• Getting clinicians to lead the change• Describing the local case for change• Clear and consistent messaging• Building shared goals in local health and care systems• A can-do approach to information governance and
technology solutions• Generating hope that the new care models can be
successfully delivered• Using public and patient demand to support spread• Invest heavily in different ways of sharing learning• Create the time, space and resources for change at this
scale
North East Sustainability Transformation Plan and Spread of
New Care Models
Digital Care and Technology
DIGITAL CARE AND TECHNOLOGY
The Gap – Why Change is needed
• Support people to live healthier lives and use care services less
• Transform the cost and quality of services when they are needed
• Unlock insights for population health management at scale
• Support the development of future medicines and treatments
• Putting data and technology to work will help ensure that health and care provision in the NHS improves and is sustainable
• Key part to play in helping local leaders across health and care systems meet efficiency and quality challenges
Future state and ambition• More patients treated locally in the
local community• By 2021 the Great North Care
Record will enable information sharing
• By end 16/17 we will be sharing of GP records across all providers
• The GNCR will support frontline care, individual self-management, planning and research
• Patients, carers and citizens will use tech to help control conditions
• Increasing digital maturity of secondary care providers
• Digitally enabled health and care system - from isolation to integration
• A paper free system
Must Do’s
A treatment summary is sent to the GP at the end
of treatment
Streamline elective care outpatient redesign
avoiding unnecessary follow-ups
Provider efficiency measures include:
implementing pathology service and back office
rationalisation
Ensure the sustainability of general practice
Investment in training practice staff and
stimulating the use of online consultation
systems
All patients have a holistic needs
assessment and care plan at the point of diagnosis
Enable and fund primary care to fully implement
framework for improving health in care homes
Reduce the proportion of ambulance calls that result in avoidable
transportation to A&E
Measure and improve efficient use of staffing resources ensure safe,
sustainable and productive services
DIGITAL CARE AND TECHNOLOGY
Patient access
Protocol Pharmacies
Wifi, Acute,Community
End of Life,GP referrals
A&E, 111Child protection
Social careaccess
Portal accessRemote consult
ElectronicCommunications
Patient update,Tracking
