Breakout session 2 Plenary 10'55 11'45

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Breakout session 2 Plenary 10.55 11.45
Whole system care, and the older patient journey
Elizabeth Wilson Victorian Travelling
Fellow Peninsula Health 5th May, 2005
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Patient Flow Collaborative Whole System Care
The Older Patient Journey
ELIZABETH WILSONPENINSULA HEALTH5TH MAY 2005
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Whole System Care The
Older Patient Journey

• Overview
• Goal of Victorian Travelling Fellow
• Key drivers for change in the NHS
• New/redesigned rolespilot projects
• Extended roles
• Strategies to decrease ED pressure
• Strategies to keep elderly at home
• The way forward

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Whole System Care The
Older Patient Journey

• Victorian Travelling Fellowship 2004/5
• Goal
• Examine new roles of Assistant Care Practitioner
  and extended health care worker their potential
  for
• introduction to Victoria in areas of
  shortages
• decreasing inappropriate presentations to
  ED
• use to assist the elderly to stay at home

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Whole System Care The Older Patient
Journey
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Whole System Care The Older Patient
Journey

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Actual
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Identify successful strategies for helping the
elderly stay at home
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Examine new/blended/expanded roles
Identify successful strategies to decrease
inappropriate attendances to ED decrease LOS
in ED
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Victorian Travelling
Fellowship 2004/5
Actual
Identify successful strategies for helping the
elderly stay at home
Examine new/blended/expanded roles
Identify successful strategies to decrease
inappropriate attendances to ED decrease LOS
in ED
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Whole System Care The Older Patient
Journey

• Key in Drivers for Changes within NHS
• NHS Plan for health care reform 2000
• Increasing demand for healthcare
• (European Working Time Directive)
• Exacerbating shortage of nurses as
  nurses extend to take up Drs roles

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Whole System Care The Older Patient
Journey

• NHS Plan 2000
• Consultation showed that public wanted
• More and better paid staff using new ways of
  working
• Reduced waiting times and high quality care
  centred on patients
• Improvement in local hospital and surgeries
• NHS seen as 1940s system working in 21st Century
• Lack of national standards
• Old-fashioned demarcation between staff and
  barriers between services
• Lack of clear incentives and levers to improve
  performance
• Over-centralized with disempowered patients

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Whole System Care The Older Patient
Journey

• NHS 2000 Budget
• Allowed for growth in real terms by 1/3 in 5
  years
• More beds, hospitals, doctors, nurses
• Modernization of premises, equipment and
  systems
• Investment to be accompanied by reform
• National Standards with regular inspection
  by independent Commission for Health
  Improvement
• National Institute for Clinical Excellence
  to ensure access to cost effective drugs not
  dependent on address
• Modernization Agency to spread best
  practice
• Earned autonomy with devolvement of power
  to local health services once modernization
  progresses and organizations work well for
  patients

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Whole System Care The Older Patient
Journey

• For the first time
• Social services and NHS to come together and pool
  resources
• Modern contracts for GPs and hospital doctors
• Nurses and allied health staff opportunity to
  extend roles
• Patients will have a real say in NHS
• NHS access to private facilities
• By 2004
• GP appointments available within 48 hours
• 1000 specialist GPs taking referrals from GPs
• Long waits in EDs will have ended
• By 2005
• Max wait for OP will be 3 months and for
  inpatient treatment, 6 months

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Whole System Care The Older Patient
Journey

• Older people use NHS more than any other group
• NHS Plan will provide for
• free nursing home care
• a 900m BP package by 2004,of new intermediate
  care services to allow older people to live more
  independent lives
• national standards for caring for older people to
  ensure that ageism is not tolerated
• breast screening for all women 65 to 70 years old
• personal care plans for elderly people and their
  carers

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Whole System Care The Older Patient
Journey

• Initiatives to support NHS Plan 2000
• 1)Shift of balance of power
• 2)National Service Frameworks including
• 3)Agenda for Change/New Ways of Working

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Whole System Care The Older Patient
Journey

• Initiatives to support NHS Plan 2000
• 1)Shift of balance of power
• i)Patients and staff to be at heart
  of NHS
• PALS and PPI
• ii) Local Primary Care Trusts to
  have role of running NHS and improving
  care in their areas

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Whole System Care The Older Patient
Journey

• System of patient and public involvement in
  health in England. This replaced Community Health
  Councils and comprised following bodies and
  duties
• The Commission for Patient and Public Involvement
  in Health (CPPIH)
• Local Authority Overview and Scrutiny
  Committees (OSC)
• Independent Complaints Advocacy
  Services (ICAS)
• Patient Advice and Liaison Service (PALS)
• The Patients Forum
• A new duty to on the NHS to involve and consult
  the public
• The aims and objectives of this strategy are
  quite simple by modernising to improve the way
  we work and run our services we aim to improve
  the patient experience and patient journey
  through the Trust. Patient and public involvement
  needs to be carried out at two levels. This is at
  an individual level and at a collective level.

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Whole System Care The Older Patient
Journey
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Whole System Care The Older Patient
Journey

• Initiatives to support NHS Plan 2000
• 2) NATIONAL SERVICE FRAMEWORKS
• 2.i) NSF OLDER PEOPLE Standards
• Rooting out age discrimination
• Person-centred care
• Intermediate care
• General hospital care
• Stroke care
• Falls care
• Mental health care
• Promoting an active healthy life

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Whole System Care The Older Patient
Journey

• A TOOLKIT
• FOR OLDER
• PEOPLES
• CHAMPIONS

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Next 2 years

• PARTNERSHIPS FOR OLDER PEOPLE PROJECTS
• 60M bp RING FENCED FOR INITIATIVES to be tested
  and evaluated over the next 2 years WHICH
• PROVIDE PERSON CENTRED INTEGRATED CARE FOR OLDER
  PEOPLE
• ENCOURAGE INVESTMENTIN PREVENTATIVE APPROACHES,
  WHICH PROMOTE HEALTH, WELL-BEING AND INDEPENDENCE
  FOR OLDER PEOPLE
• Available for local authorities to make joint
  application with PCTs, District Council,
  NHS,voluntary and independent sectors

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Whole System Care The Older Patient
Journey

• Initiatives to support NHS Plan 2000
• 2) NATIONAL SERVICE FRAMEWORKS
• 2.ii) LONG TERM CONDITIONS
  (CDM)Standards
• Person centred service
• Early recognition followed by
  prompt diagnosis and treatment
• Emergency and acute management
• Early and specialist rehabilitation
• Community rehabilitation and
  support
• Vocational rehabilitation
• Equipment and accommodation
• Personal care and support
• Palliative care
• Support to family and carers
• Care during admission to hospital
  or other health or social care setting

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Whole System Care The Older Patient
Journey

• Chronic Disease Management Levels
  of Support

Case Management
Level 3 Highly Complex Members
Disease Management
Level 2 High Risk Members
Level 1 70-80 Chronic Care Management
Supported Self Care
Supported Self Care
Population Wide Prevention
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Whole System Care The Older Patient
Journey

• Case Management for people with CD and older
  people
• 20 population require 80
  care
• Castlefields-Improving chronic care in General
  Practice
• A managed care approach nurse and social
  worker
• Dr David Lyon GP Outcomes
  1000 bed days saved pa
• GP home visit
  requests reduced by 30 over 2 years
• Unique Care
• Kaiser Permanente-Evercare
• LOPSDP

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Whole System Care The Older Patient
Journey

• Expert Patient Programme US originatedprincipall
  y a user led self-management programme for
  creating expert patients.
• Outcomes early days but 23 reduction
  in CHD deaths and 10 fall in cancer deaths
  in 6 years

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Whole System Care The Older Patient
Journey

• Initiatives to support NHS Plan 2000
• 3)Agenda for Change/New Ways of Working
• (All initiatives supported by
  Modernization Agency)
• Draws together teams of experts to act as
  catalysts for significant and sustained
  improvement in every healthcare setting.
• Teams included
• The Leadership Centre
• The National Primary and Care Trust
  Development Programme
• The National Primary Care Development Team
• The NHS Clinical Governanne Team Support
  Team
• Service Improvement Team (and the National
  Institute of Mental Health)
• The Redesign Team
• The New Ways of Working Team

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Whole System Care The Older Patient
Journey

• Underlying principle of Redesign of
  Workforce
• Patient at centre of care rather than
  traditional work practices, professional
  boundaries and staff preferences dictating care

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Whole System Care The Older Patient
Journey

• Changing Workforce Programme
  
• Purpose
• To improve services to patients the working
  lives of staff
• National programme to help those in services to
  redesign roles
• Education collaborations nationwide

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Whole System Care The Older Patient
Journey
MORE SENIOR STAFF
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8
CONSULTANT PRACTITIONERS
ADVANCED PRACTITIONERS
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SENIOR/SPECIALIST PRACTITIONERS
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PRACTITIONERS
5
ASSISTANT/ASSOCIATE PRACTITIONERS

• 4

3
SENIOR HEALTHCARE ASSISTANTS/TECHNICIANS
2
SUPPORT WORKERS
1
INITIAL ENTRY LEVEL JOBS
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Victorian Travelling
Fellowship 2004/5

• Role redesign
• Individuals can take on different tasks or the
  task can move between different levels of skill\
• Can encompass four types of changes
• Moving task up or down traditional
  unidisciplinary ladder
• Expanding breadth of the job AH/RN
• Increasing the depth of a job CNC
• Combining tasks in a different way

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Whole System Care The Older Patient
Journey

• Re-designed New Roles Pilot Projects

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Victorian Travelling
Fellowship 2004/5

• Points of Difference UK/Australia
• UKphased out Div 2 nurses over a decade ago
• Health Care Workers have had expanded roles
  
• New roles based around competency
• Health, Social Services and Higher
  Education sector funded by same level of
  Government
• Australia more regulation conscious
• Nurse Practitioners specific requirements
  and registration with NBV
• Some hesitation around competency-safe
  haven of regulations
• Federal/State split of responsibilities

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Whole System Care The Older Patient
Journey

• Blended/Extended roles
• Emergency Care Practitioner --Ambulance
  attendant/ED
  nurse
• Nurse consultants on Reg roster
• Night nurse practitioners---hospital at night
• Surgical/anaesthetic assistant( nurse)

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Foundation Degree in Health Social Care
Fd Level 1
Fd Level 2
Post Fd career
Associate Practitioner Orthopaedic Intermediate
Care
New roles in the workforce
Associate Practitioner Children Families
Generic introduction to health and social care
Associate Practitioner Mental Health or LD
Associate Practitioner Generic acute care
Pathway to Nursing
Application to year 2 and 3 of BSc(Hons) in
chosen profession
Common Learning IPLU1
Pathway to Occupational Therapy
Pathway to Physiotherapy
Pathway to Podiatry
Pathway to Social Work
Pathway to Audiology
www.hciu.soton.ac.uk
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Decreasing inappropriate attendances to ED,
LOS in ED wards

• .

Admitting team located in MAU all shift
No/clerk triage unless Very busy
Nurse led Walk in Centres
Appropriate presentations to ED Decreasing LOS in
ED/wards
Nurse Consultants ED/med/surg
Physio Practitioner/ consultant
Consultants admit direct to ward under
relevant unit
Nurse led Minor Injuries Units
Surgical assessment units
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Keeping the Elderly /or chronically ill at home.

• .

Emergency Practitioners
Consultant Practitioners
Care (case) Management
Keeping the elderly at home
Assistant Care Practitioners supporting tradition
al allied health, nursing carer functions
Allied health /or nurse led clinics
Expert patient programmes (chronic disease)
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Issues supporting changes

• Strong Leadership from Govt NHS
• Resources for change management
• role re-design training
• Whole system change--communication
• Multiple collaboratives to support pilots
• Supportive unions colleges

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Outcomes

• (Winter 2004/5 DHS Report)
• 
  2000/1 2002/3 2004/5
• Flu vaccine uptake over 65s 65
  72
• GP within 2 working days 75
  99
• Patients spending 4 hours or less in ED
• (Including WIC / MIU from 2003/4 ) 77
  97
• Cancelled Operations/ booked 3.4
  1.3

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Population facts (Aus)
ABS(2001)Population trends for the 21st Century
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The Way Forward

• Australia
• N3 ET National Nursing and Nurse Education
  Taskforce
• (Recommendations from 2002 National
  review of Nurse Education
• including scope of
  practice of nurses and others)
• Victoria
• DHS/VQC-Patient Flow Collaborative/HDM/HARP
• Debates re blended training at TES
• DHS Nursing Policy Branch/NBV scope of practice
  issues
• Health Services
• Complex Care Team
• RAD teams
• Streamline clinicnurse prompted analgesia,
  investigations
• Direct admissions ED to RAPCS
• Physio specialist in ED Rosebud
• Proposed expanded role of Div 2 nurses
• Development of advanced practitioner roles

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Key Issues

• Patient at centre of care
• Thinking outside the square
• Breaking down barriers between traditional roles

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• Questions

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