Shifting the Balance of Care through SPACE

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Shifting the Balance of Care through SPACE

• Sylvia Wyatt
• Alex Davidson
• Vicky Irons
• Gerry Marr

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• Sylvia Wyatt
• SPACE lead for
• Shifting the Balance of Care

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SPACE
Strategy and Policy Analysis CollaborativE
Changing the way we do things
SPACE to make things happen
Changing the framework

• Policy
• Principles
• Fixed points
• Directions of travel

• Business as usual
• Meeting targets
• Crisis management
• Ensure safety
• Resource management

• Independent safe space to
• Think
• Experiment
• Challenge
• Create
• Support
• Influence

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Overview of SPACE
Real world
High impact changes
SPACE
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SPACE process for SBC
Defining the SBC problems?
Agreed list of issues
All possible solutions to issues
Feasible solutions
High impact changes
Brain storming
Evidence and policy constraints
consensus
Impact Feasibility Scalability Cost
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What is shifting?
Location of care
Upstream prevention
Central
Local
How care is delivered
Roles and responsibilities for care
Workforce shortages
New medical discoveries
Funding shortages
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What do we want to shift?

• Focus more prevention, continuity ownership
• Ways of working new roles, expertise teams
• Location of services more care closer to home

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Main areas for SBC
Specialist health needs
Specialist inpatient healthcare
Increasing dependency
Secondary to primary
Long term conditions
Empowered carers
Self-care and carers
Health needs
Increasing health needs
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Evidence What may or may not shift activity
from hospital to community ?
What may work (lack of evidence)
What may not work
What does work
telecare care
Targeting high risk
GPwSIs
Smart houses
Tele consultations
Home monitoring
Direct GP access to tests
Case management
Substituting nurses for docs
Anticipatory care
OPDs in primary care
selfcare
Primary care follow-up
Remote diagnostics
Direct payments
Patient held records
Choice about Eol
MDTs
Pooled budgets
Discharge planning
Rapid access clinics
VC Social networks
Hosp _at_ home
Local care centres
Twilight care care
Transport
Partnership with vol orgs
Video conferencing
More home visits
Intermed care responses
Source HSMC Birmingham 2006 Rapid review of
Shifting hospital care into the community
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Who will benefit and organisations involved?
Isolated people
transport
People who cannot travel easily


communities
Voluntary organisations
People who need support
Care home providers
carers
housing
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High impact changes

• Maximise care at home with carer support
• Integrate health social care and support for
  people in need
• Reduce variation in unscheduled admissions to
  hospitals
• Improve capacity demand management for
  scheduled care
• Extend scope of services provided outside acute
  hospitals
• Improve access to care for remote and rural
  populations
• Improve end of life care (EOL)
• Improve joint use of resources ( facilities,
  information, technology and staff)

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What are we trying to improve?
High impact changes
SBC shifts/improvements
National outcomes framework
Improved individual experience

• Maximise care at home
• Integrate health and social care and support for
  people in need
• Reduce variation in unscheduled admissions
• Improve capacity demand for scheduled care
• Extend the scope of services provided outside
  acute hospitals
• Improve end of life care (EOL)
• Improve access to care for remote and rural
  populations
• Improve joint use of resources

Increased independence and personal choice
Single outcome agreements
Adverse events prevented by earlier interventions
Decreased institutional beddays
HEAT targets
Better use of medical and non medical
professionals
Fully employed existing technology
Reduced inequalities in time and geography
Reduced infrastructure costs and carbon footprint
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2. Defining shift/impact
Low Impact/shift High volume
High Impact/shift High volume
Increasing volume
Low Impact/shift Low volume
High Impact/shift Low volume
Need robust definition of impact/shift
Increasing impact/shift
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2. Possible definition of shift/impact

• Shift number of people x units of shift
• Examples
• Appropriate care beddays saved by earlier
  discharge
• Empowerment number of people receiving self
  directed support payments
• Location number of beddays saved by increasing
  home care
• EOL hospital admissions/beddays avoided by
  people dying with dignity at home
• Anticipatory care No of people with higher
  quality of life for longer through earlier
  diagnosis

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Current work

• HIGH IMPACT TCHANGES
• Maximise care at home
• Reduce variation in unscheduled care
• Increase care effectiveness and safety for
  people in need.
• Improve demand and capacity for scheduled care
• Extend scope of non-medical services outside
  hospital
• Develop generic rural support services
• Improve end of life (EOL) service at home and in
  care homes
• Better joint use of resources

Completeness
T E S T
Evidence and good practice
Outcomes/shift/impact
Feasibility
High impact changes
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Joined up working
Health
Social
Joint futures Intermediate care Inequalities Partn
ership working Third sector Telecare Remote
rural
Long term conditions E health Local care
centres Changing the way we work Mental health
strategy
Changing lives Self directed payments Adult
protection Independence Empowerment
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• Working Together
• Alex Davidson
• Joint Improvement Team Associate

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The Joint Improvement Team

• Established in 2005
• To provide direct support and assistance to
  Health and Social Care Partnership
• Aim help accelerate the pace of service
  improvements.
• Uses continuous improvement
• Partnership and Outcomes Division

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Support Areas

• Review of whole system working
• Assessment and Diagnosis
• Focused support over a period of 12-18 months to
  specific Partnerships
• Performance improvement/action plans
• Significant resources allocated financial and
  JIT personnel

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Whole System approach
Balance of Care
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Information and AdviceShared Learning

• National Website
• National Learning Events
• Focussed work (e.g. Care at Home services)
• Good Practice (e.g. Essential Connections)

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Developmental Support

• Mental health
• Learning disability
• Long Term Conditions/Disability
• Community Equipment and adaptations
• Care models housing
• Governance CH(C)P development

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Is your structure fit for purpose?
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Development Programmes

• Capacity Planning
• Commissioning
• Catalyst for Change
• Intermediate Care/Rehabilitation
• Governance and Management
• UDSET and outcomes
• Organisational Development Work

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National Development Programmes

• Telecare
• Housing Demonstrators
• Community Equipment and Adaptations
• Financial Frameworks (cost cube)
• Digital Stories
• Switch Partnership
• Transport

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Risks of Getting Boxed In In our Thinking
Out-of-the box thinking requires an openness to
new ways of seeing the world and a willingness to
explore. Out-of-the box thinkers know that new
ideas need nurturing and support. They also know
that having an idea is good but acting on it is
more important. (Ed Bernacki)
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and some tools

• Partnership Outcomes Performance Improvement Tool
  (POPIT)
• User Defined Service Evaluation Tool (UDSET)
• Capacity Planning Tools Older People and
  Learning Disability
• Partnership Enhancement Assessment Tool (PEAT)

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Any Questions
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• Vicky Irons
• General Manager
• Glenrothes North East Fife CH

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• Key Driver Clinical pathways
• Underpinning action plans  
• Demand side referral service (4 stages)
• Community infrastructure premises
  infrastructure, diagnostic and treatment capacity
• Workforce modernization and training
• Patient empowerment
• Discharge management

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DRAFT 1 - OVERVIEW OF FIFE CHD INTEGRATED PATHWAY
PRIMARY HEALTH CARE Primary Prevention Targeting
health inequalities/communities of
interest Lifestyle changes KEEPWELL Health
Improvement Healthy Living centres Increase CV
risk assessment screening Ambulatory BP
monitoring Secondary prevention (SP) Systematic
referral pathways Implement SP standards Lifestyle
change self care Treatment optimisation Chest
pain Screening appropriate referral Management
of stable angina Follow up (discharge) Heart
Failure Assessment appropriate
referral Structure annual review in line with
standards In reach model developed Self
management plans Anticipatory care/case
management (utilising SPARRA etc) Palliative
care Cardiac Rehab In reach model single
point of access Deliver Phase 2
3 Assessment Extend service provision
initiation for other conditions CBT
Psychology Arrhythmia Increase screening Baseline
assessment referral
SECONDARY CARE Prevention Patient education
(inpatient outpatient) Referral pathway to
primary care service Chest pain
Management Specialist assessment, diagnosis,
treatment, follow up Rapid access chest pain/risk
stratification ACS Managed in CCU Cardiology
ward Referral to Tertiary care Initiation of
management plan Heart Failure Assessment
diagnostics Specialist follow up inpatient
treatment Initiation of management plan Cardiac
Rehab Assessment initiation of phase
1 Initiation for other conditions Arrhythmia Speci
alist assessment diagnosis Cardioversion F
ife service for implantable
defibrillators Other Cardiac imaging Specialist
treatment of other cardiac conditions
TERTIARY CARE Chest Pain Management Angiogram Angi
oplasty CABG Heart Failure Transplant Advanced HF
service Arrhythmia Pulmonary Vein
isolation Device insertion/removal Other Adult
congenital heart conditions
COMMUNITY SERVICES Prevention Wider health
improvement Public Health Promotion
Campaigns KEEPWELL Lifestyle change
services Chest Pain Management Self
assessment Cardiac Rehab Long Term maintenance
(Phase 4) Self assessment (re-access) Self
Care Heart Support groups (Patients
carers) Structured patient education Buddying/volu
nteering Voluntary sector (BHF,CHSS,Carers) Inform
ation in websites Self management plans


INTERMEDIATE (To Tertiary) Strengthen links
between centres Regional planning Direct referral
to primary care for rehab Direct ambulance
transfer from primary care for primary
angioplasty Clear referral pathways linking to
primary secondary care
INTERMEDIATE CARE (Primary Secondary
care) Develop community resource centres for
diagnostics, assessment, treatment to follow up
(eg Cardiac Rehab, Heart failure) using
GPWSI/Specialist staff/Nursing/AHP Referral/discha
rge pathways/transitions/triage Ambulance Service
Thrombolysis PCES NHS 24 Co-ordination of
in-reach/out-reach services
UNDERPINNING STRUCTURE E-Health/Tele health
Workforce planning Multidisciplinary/
Multiagency Involvement Standards Equity
inclusion Patient Staff
education Patient Safety Patient/Carer
experience/PFPI MKN
Audit/Evaluation/Research Corporate/Financial
Governance Clear patient pathways/journey
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Shifting The Balance of Resources Gerry
Marr Chief Operating Officer NHS Tayside
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Budgets

• Historic

Corporate/Facilities
Cost Cube
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Cost Cube
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Analysis of Spend
1,567
Locality/CHP 17
Practice 27
Patient 49
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Current system Practice direct Impact

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Locality or CHP
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Current system

• Does not matter who does what with 673/head
• Hide behind Clinical Decision Making
• Prescribe anything Atrorva any statin (!)
• Refer 1 or 10 patients a surgery
• Admit zero or 20 a week
• What is the relationship between SW NHS
• So What ?

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Current systemGP Direct Impact

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Current system
Highland Council Social work 2006/07 Spend/head
(gt75yrs) for Multi-Member Wards

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Current system

• Within NHS Board Shared Bottom line
  responsibility, but
• 1) CHP / DGH / Mental Health 49.5 of Elderly
  Emergency Admissions do not impact on CHP budget
• 2) Corporate/Direct Health Services No
  Budgetary Relationship, it just is 160/head
• 3) Between Board and GMS Practices Contract for
  GMS Enhanced Services 266/head but what
  about
• New Outpatient referrals
• Prescribing
• Investigations
• AE attendances
• Emergency Admissions
• Directly affected by Practices but no contract
• Value 673/head

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The Future for the Current System
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Any Questions