Long term conditions

personalised responsive effective innovative

Jude Smith

Respiratory Nurse Consultant & Long Term Condition Lead

24th March 2011

Transforming Community ServicesLONG TERM CONDITIONS

Background• As part of Transforming Community Services,

Leicestershire County and Rutland Community Health Services intended to provide a model of integrated, streamlined care for patients with Long Term Conditions (LTC)

• A key part of this model was the development of a LTC Hub to bring together all health professionals involved in the care of people with a LTC under one integrated service.

personalised responsive effective innovative

What is a Long-Term Condition Hub?

• Not just a SPA

• Hub and spoke

• Integrated patient management service

• Brings all patient generic tasks together in one place- freeing up clinician time

Current Situationpersonalised responsive effective innovative

GPs HospitalsPatientsCommunity

TeamsConsultantsSocial/

Voluntary Care

LTC Clinicians / Community Matrons

Administration

• Multiple communications (calls, emails, referrals, faxes, letters, etc) to and from all LTC staff, resulting in less time to care

• Clinical staff are pulled away from core duties by administrative tasks• Over-dependence on individuals being available• Low levels of administrative support

Future Planpersonalised responsive effective innovative

GPs HospitalsPatientsCommunity

TeamsConsultantsSocial/

Voluntary Care

LTC Clinicians / Community Matrons

LTC Hub

• Streamlined communications to and from LTC Hub, supported by clinical triage• Full administrative support for clinicians, resulting in more time to care

Triage

Key Features (current thinking)

• Hub open Mon – Fri 9am to 5pm, with enhanced OOH support from existing OOH team

• Manned by c.6 Case Coordinators• Located in Fosse House, from late Oct/early Nov 2009• Dedicated telephone numbers for patients and

professionals• Clear, documented processes (care pathways, referrals,

call handling, data entry, diary management, hand-offs, correspondence, service level targets, etc)

• Two clinicians within the Hub each day (approx. one working day in seven). One will focus on triage, the other will support triage activity and have ring-fenced admin. time.

personalised responsive effective innovative

Key Benefits• Improved access to LTC team for patients and

professionals, especially when staff are away (holiday, training, etc)

• Reduced administration for LTC clinicians/CMs – more time to care

• Better use of Trust resources. Streamlines patient services

• Increases productivity of clinicians• Promotes integration both internally and externally• Brings accountability of service delivery from the point of

referral• Increases cost-effectiveness

personalised responsive effective innovative

Steps we took• Staff engagement process in August 2009 to inform

future service delivery, followed by 30 day Consultation Period

• Design and build of Hub– Recruitment and training of Case Coordinators– Cross-training of clinicians (subject to service design)

– SystmOne enhancements– Process design– Capacity planning (across all LTC roles)– Communication programme (to GPs, hospitals, etc).

personalised responsive effective innovative

Screen, Diagnose Optimize Care

Case manageAcute response Care co-ordinationSpecialist interventions

End Of Life

General Practice

Community Teams

Secondary Care

Social Care

LTC HubAdminReferral managementWorkforce developmentTeam managementOOH

COPD

HF

Diabetes

Neuro

ComplexElderly

EOL

Referrals to•GP•Community teams

•DN•Intermediate Care

•Social Care•Secondary Care

Case Finding•Health Utilisation•VHIU= MDT

Review

Implementation• Project title: LCR CHS SPA/LTC Hub Project Manager: JP• Report coverage: Week ending 23.10.09 Update number: Status Report 4• OverviewProject Status GREEN AMBER RED

• Workstream Milestones and key tasks completed for week ending 23.10.09• Project Management Updated detailed action plans• HR, Recruitment and Training• Assessed initial (four) responses to Service Coordinator secondment positions (from LTC admin.

& OOH)• Email sent to wider PCT advertising Service Coordinator secondment positions to generate more

candidates. To date this has generated one definite candidate, with possibly one more• Further discussion re. scope of change for LTC clinicians (shift hours when in Hub)• SystmOne refresher training for clinicians• Updated training requirements, and commenced population of training material• Processes & MISRecalculated capacity plan for LTC clinicians• Reviewed Adastra requirements for LTC patients (call logging, special patient notes, reporting)• Communication• Prepared patient pack for sign-off• Attendance at strategy group (Noel O’Kelly) to identify best approach to GP community• Progressed copy for CHS magazine and intranet• IT & Telephony • Reviewed call routing/numbering for LTC patients into the SPA/Hub

Implementation• Good News Nothing new to report• Issues/Risks arising this week• Providing basic LTC patient data to OOH, EMAS, etc identified as a risk as it may breach patient confidentiality. This will be

reviewed in conjunction with Information Governance.• Milestones and key tasks planned for week commencing 26.10.09• Project Management• Update project and strand plans• HR, Recruitment and Training• Assess PCT responses to Service Coordinator secondment positions• Initial discussions with candidates for Service Coordinator secondment positions• Finalise scope of change for LTC clinicians (shift hours when in Hub)• Confirmation of level of LTC training required for SPA nurses• Complete and submit Management of Change paper• Commence consultation process with existing LTC clinicians and administrative staff• Training design meeting, and further population of training material• Processes & MIS• Complete call handling script• Formatting of key Hub processes for formulation into handbook• Confirm that Adastra requirements for LTC patients can be delivered• Further review of dataflow requirements/feasibility• Review of Rotamaster as possible tool for scheduling LTC clinical cover• Communication• Alter patient pack to reflect decisions on phasing the service• Progress copy for CHS magazine and intranet• Meeting to introduce Hub to EMAS etc on 29th October• Noel O’Kelly to update project on approach to GP communication• IT & Telephony• Confirm call routing/numbering for LTC patients into the SPA/Hub

Implementation- KPI’s

• Heart Failure• Reduced mortality rate• Patient satisfaction• Avoidance of hospital re-admission• Number of hospital admissions• Number of patients on the correct medication• Patients are managed in accordance with

national guidelines e.g. NICE

Communication• Mailing Action Who By• PATIENT MAILING (Approx. 1,800)• Manage agency to print letters, leaflets, ID card 23rd November• Manage agency to attach ID card to letter 23rd November• Manage agency to stuff letters and leaflets into envelopes, and deliver to Fosse House

26th November• Ensure that LTC patient database is accurate, and printed onto address labels (in a CHS site)

26th November• Arrange for CHS staff to attach address labels (must take place in location that address labels

are printed) 30th November• Arrange for Fosse House post room to frank and post letters, and post out 2nd Class on 2nd

December 2nd December• GP MAILING• Write GP letter, and get it proofed and approved 26th November• Manage agency (or internal dept) to print letters and posters 27th November• Manage agency (or internal dept) to stuff letters and posters into envelopes, and deliver to Fosse

House 30th November• Ensure that GP database is accurate, and printed onto address labels (in a CHS site)

30th November• Arrange for CHS staff to attach address labels to envelopes (must take place in location that

address labels are printed) 1st December• Arrange for Fosse House post room to frank and post letters, and post out 2nd Class on 2nd

December 2nd December

Staff rotaCM AL H X HA

CM H HA X

CM H X X X X X

COPD X X HA X X X X X H

COPD AL X X X H AL AL X X X X

COPD NWD NWD NWD NWD NWD NWD AL

COPD X HA X

Diabetes HA NWD H NWD

Diabetes HA H

Diabetes NWD H NWD NWD NWD NWD

Diabetes HA

Diabetes H

Heart Failure X X X X X HA X X

Heart Failure X NWD NWD NWD NWD NWD NWD NWD

Heart Failure SL X NWD NWD H NWD NWD

Heart Failure X X X X X X X

Heart Failure AL AL AL AL AL UNI X HA

Heart Failure NWD X NWD NWD H NWD NWD

Heart Failure X NWD NWD X NWD NWD NWD

Clinician capacity plan

The Launch

The Launch

The Launch

Where we are now

• 160 calls per week Patient LTC line and HCP line

• 95% of calls answered in <60 seconds

• Average speed 0.26 seconds

• 3002 referrals year to date

• Management of change process

• Reduction of staffing 1.2 wte HF, 2.0 wte Resp, 8% of DSN time

The Future?

• Platform for telehealth

• Extending the hub for other services

• PBC