Principal Community Pathways

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Sunderland & South Tyneside

Principal Community PathwaysA 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

Principal Community Pathways – TimelineJan 14

Design Test Implement

Design Test

Apr 14 July 14

Implement

Oct 14 Jan 15

Pre-engagement

Design Test Implement

Pre-engagement

Apr 15

Tranche 2 – Northumberland &

North Tyneside

Tranche 3 – Newcastle & Gateshead

Tranche 1 – Sunderland & South

Tyneside

What will be different?Current Experience

• There are lots of confusing ways to access services

• Most non urgent services operate Monday to Friday 9 – 5, and there are waiting lists

• Treatment episodes cannot always be linked to an outcome or a nice guidance recommended treatment, staff often have to refer to others for treatment

• Patients can bounce around the system• Staff time is taken up with typing, driving

and admin • Patients stay in services for a long time due

to lack of joined up working and support to help them recover

• Patients don’t want to be discharged because it’s hard to get back into services

Our Commitment• There will be a single point of access for all

referrals• Most non urgent services will work from

8am – 8pm, and waiting lists will be minimal• Treatment packages will be evidence based

and staff will be trained to deliver a broader range of nice recommended interventions

• Principle of ‘no Bouncing’• Staff will have twice as much time to spend

with patients • Services will have a recovery focus from

day 1. Integrated working will improve the quality of life for service users.

• Service users will be able to re access services easily and quickly if they need to.

Urgent

Routine

Huddle

Triage Team

Single Point of Referral

Non-complex

Clinical Diary

Complex Clinical Diary

11

Triage & Action

IRT

RapidResponse

Nurses

UCTHome Based Treatment

Assessment

Gatekeeping

Single Point of Access

Psychosis and Non-Psychosis

Cognitive

Learning Disabilities

Sunderland Team Configuration

Psychosis

Non-Psychosis

Step Up

EIP

PD

Shared Resource

Sunderland x 3 teams

Psychosis

Non Psychosis

Step Up

EIP

PD

South Tyneside x 1 team

Psychosis/Non PsychosisClinical Leads

Shared ResourceStep Up hub

Psychosis and Non-Psychosis Teams

Community Team

Step-up / Day Service

MPS

Sunderland

Community Team

Step-up / Day Service

South Tyneside

YPD

Challenging Behaviour

Central Resource

Cognitive & Functional FrailClinical Leads

Cognitive & Functional Frail Teams

Challenging Behaviour

Physical Health

Sunderland

Mental Health

Learning DisabilityClinical Leads

Learning Disability Teams

Current State

Future StateStaffing

Communication

Clinical Risk and Continuity of Care

Caseload Migration

Performance Management

Safety

Phased Transition ProcessMay 14 Dec 14

Evaluating PCP

Strategic Driver

Improve QUALITY for the patient

PCP Benefits

Improved outcomes and experience

Improved safety

Improved outcomes and effectiveness: Substantially more evidence-based interventions; recovery focus; care pathways and packages; time well spent with patientsImproved experience: patient and carer-centred services; care closer to home in the community; partnership approach; service user and carer involvement in design, collaborative ways of working, easy access and re-access of servicesImproved environments: good quality venues, accessible locations

Strategic Driver

Reduce COST

PCP Benefits

Reduced reliance on inpatient beds

Efficient services

Improved flow: Alignment of the pathway across community and inpatient services; fewer admissions; reduced length of stay; better discharge planning; better transitions & partner working; balanced flow of access and dischargeEfficient clinical services: New systems and processes; IT revolution; reduced bureaucracy and waste

Strategic Driver

SUSTAINABLE services

PCP BenefitsSkilled workforce

Partnership and integration

Improved skills: Clinical skills development programme; evidence-based interventionsImproved teams and team-working: Aligned to patient need; new systems and processes; MDT working; team resources aligned to demandWilling partners and integrators: This can only work well as part of an aligned whole system

PCP Benefits

What Current Future

Community clinicians• % direct time with patients• % time non-patient activity• % record keeping• % Travel

20%45%25%10%

49%36%5%

10%

The difference we can make by having more time with patients

Contain patient risk; little opportunity for evidence-

based interventions

Focus on a range of evidence-based interventions that support

recovery and improved outcomes

System of Access for patients (non-urgent referrals)

Variable system, team allocation meetings, bouncing

Simple, standard system; early allocation of pathway; booked

directly; no bounce

Typical Waits• To first contact• Assessment to treatment

4-6 weeks6 weeks (range 2-10 wks)

1 week< 2 weeks

% split of resources Community to Inpatient 48% 52% 60% 40%

What to expect - the Numbers (adult and older people)

Quality and Safety Data SuiteDeveloped by senior clinicians to monitor and measure the impact of

transformation across the Trust, designed to answer:

How will we know what difference has been made?

Does the PCP model work?

• Have outcomes for patients improved?• Do service users and carers think the

service has improved?• Are we delivering more evidence based

interventions?• Is there a greater recovery focus leading

to reduced reliance on inpatient beds?• Have waiting times reduced?• Are clinicians spending more of their time

with patients?• Does the skill mix match demand for

services?

Is Transformation safe?

• Has there been an impact on out of area referrals?

• Has the number of readmissions and re-re-referrals changed?

• Are community services contributing to delayed discharges?

• Has the average length of stay changed?• What is the impact on community

workload?• Has there been an impact on the

proportion of incidents?• What has the impact on staff – sickness,

morale, vacancy rates?

For Service user and Carers:• Service User led narrative interviews. To be carried out over a longer period of

time to assess cultural and behavioural changes including: recovery focus, collaboration, co-production, self-management

• Satisfaction with services. To assess service user and carer satisfaction with services as delivered at a point in time

• Current feedback sources: Points of You, Family and Friends Question

For Staff:• Staff Wellbeing evaluation. To understand the impact of the model on staff

morale and well-being • Satisfaction with services. To assess staff feedback on the PCP model covering

efficiency, effectiveness, quality and safety of services • Current feedback sources: Staff Survey, Family and Friends Question

For Partners:• Satisfaction with services. To assess the impact of the model on the range of

partners we work with including Commissioners, GPs, Social Care and other health providers. To include ease of access to services, satisfaction with service response as well as overall satisfaction with services

How will we know what difference has been made?