Surrey

1
Surrey Sussex Transforming Chronic Care
Programme

• September 2005

2
What is the TCCP?

• A collaboration across the whole system (inc.
  social care, voluntary sector, patient groups,
  carers associations etc.)
• 3 year programme (to 2008)
• Outcome driven
• About people not disease
• Focused on system cultural change

3
An Integrated Approach
The Chronic Care Model Ed Wagner
4
Programme Structure
5
(No Transcript)
6
Key Elements of The Programme

• Outcomes Framework
• PCT Self-Assessment Audit
• Surrey Sussex Patients/Carers Survey
• Surrey Sussex Stakeholder Conference
• Local health economy workshops
• Service User and Carer Workshop
• Clinical and Service User/Carer Reference Groups

7
Patient Satisfaction

• Feedback from 23,738 people
• 21,148 had a LTC, 2590 looked after someone with
  a LTC
• Half knew a lot about their conditions
• Two thirds knew a lot about their care
• Half knew what all their medicines are for and
  where to get more info
• 7 out of 10 said their family did not have enough
  information

8
Involvement

• 94 thought it was important to be involved in
  planning their care
• Only one third said they felt involved
• One in five said they felt in control
• Seven out of ten wanted to be involved in
  designing new services

9
Key Elements of Workforce Development work stream

• Case Management Development Programme
• - Taught components - 2x2 week taught modules
• Care Co-ordination and Medicines Management
  Advanced Assessment and Chronic Disease
  Management
• - Case finding and specialist assessment
• One to one mentoring with experienced external
  mentors
• Problem-solving workshops
• Assessment of competence

10
Case Manager/Community Matron Development
Case management development programme
Assessment tools
Case finding
Case Management
Expert mentor support
Case manager network
Mentor development programme
11
Next steps Identifying the skills needed
throughout the triangle
Case management
C o o r d i n a t o r
Advanced skills Specialist intervention from
staff from all health social care agencies
Core skills Skills shared by all groups,
including patients and carers, statutory,
non-statutory staff and volunteers
Advanced skills
Care skills
Care skills Intervention from the health and
social care workforce
Core skills
12
Workforce Development - Current activities

• Workforce Directory of Initiatives Surrey
  Sussex
• Test sites to support and develop new initiatives
• Scoping of national and local vocational roles
• Scoping of national and local initiatives
• skills development for patients and carers
• patients and carers involved in development
  programmes/mentoring etc. for staff
• Transfer and sustainability of case
  management/community matron development into the
  2 local universities
• Engagement of further education and joint
  training

13

• Programme Director Julia Ross
• Workforce Development Facilitator Julie Van
  Ruyckevelt