Walsall

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Walsall

• Interface With Secondary Care

Trish Skitt 13, Nov 2003 Birmingham Evercare Event
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Agenda

• PCT and Secondary Care Background
• Business Case Scenarios
• Secondary Care Interfaces
• Notification of hospital admission
• APN and consultant mentoring
• HAT tool process
• Monthly business/clinical meetings
• Most challenging and support for change in
  implementing Evercare programme in Walsall
• Discussion

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PCT Background

• 1700 Employees
• 255,000 population
• 14 (41,422) gt 65 years old
• 121 GPs total in community
• High number of single-handed GPs
• 36 GPs (11 GP Practices) involved in Evercare
• 1 primary hospital-785 beds
• Incorporate MH
• Star Ratings

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Secondary Care Background

• 90 of Walsall patients go to this hospital
• Focused on reduction of avoidable hospital
  admissions
• 3.36 of the high risk gt65 drive 46 of unplanned
  admissions
• Director of Nursing and consultants support
• IT initiative to link all systems together

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Possible impact?
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Whats in it for Secondary Care?

• Managing capacity
• Meeting targets
• More effective utilisation of geriatrician
  consultant time
• Discharge planning
• Shared learning
• Coordinated diagnostic/medication management
• Knowledge of patients pre-hospital status
• Interface of primary and secondary care

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Hospital Notification Process

• System-wide IT Initiatives
• Fusion Project
• PMS Access
• Status Messaging
• Evercare cohort list/APN sent to hospital IT
• Automatically notifies APN of hospital attendance
• email
• mobile phone

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APN and Consultant Partnership

• 4 nurses paired up with 4 Geriatric Consultants
• Visit and conduct wards rounds together
• Good hospital support for documenting notes in
  hospital medical record
• Work in partnership with discharge planning team
  to streamline LOS and share learning

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Partnership Success Stories

• Admission Avoidance
• APN called consultant who made a domiciliary
  visit
• Nurses confidence
• Averted hospital admissions
• Shortened length of stay
• Enhanced quality of life
• Increase in functional status
• Pharmacy Management

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HAT Tool Process

• Started process in Sept
• Multi-disciplinary team
• Chaired by Clinical Lead
• Consultants, GPs APNs, Social Services
• Team meets monthly to discuss Evercare cohort
  admissions and determine root cause
• Shared learning
• Action plans created
• Will categorize admissions monthly to trend

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Monthly Business Meetings

• Team of clinical and management
• Shared agenda
• Shared success stories
• Communicate data results (once available)
• Issues/barriers
• Future actions

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Most challenging aspects implementing the
Evercare Programme

• Modernisation agenda of PCT/Secondary Care
• Supporting framework
• Not more of the same
• Engaging critical mass of GPs
• Confidence for service re-design
• Primary Ownership Milestone

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Supporting the Change

• Level of local commitment/leadership
• Commissioning function
• Quality of patient care
• Audits
• Support and enthusiasm of Evercare team
• PCT structures mirror national strategy
• Assists whole systems approach
• Person Centred Care
• NSF
• Enthusiasm, skills, confidence of appointed
  nurses
• Communication of patient diary events

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Questions/Discussion