Right First Time: Update

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Right First TimeUpdate
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Overview

• Making sure Sheffield residents continue to get
  the best possible health services is the aim of a
  new partnership between GPs, local hospitals,
  mental and community health teams, the City
  Council and voluntary organisations.
• The Right Care, Right Time, Right place
  partnership is particularly focusing on
  transforming and improving the way older people
  receive healthcare and also those patients who
  have long term illnesses such as diabetes, heart
  failure and dementia.

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Vision

• To ensure all Sheffields residents live longer
  and healthier lives, and are supported in their
  local community wherever possible by joined up,
  high quality, responsive, health and social care
  services which offer continuity of care, shared
  decision making, and a lifelong, personalised,
  preventative approach to health and wellbeing.

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Phase 1 Update Key Aims

• To improve the clinical outcomes for older people
  with complex needs
• To make better use of limited resources
• To improve patient experience
• TRANSFORM THE HEALTH AND SOCIAL CARE SYSTEM TO BE
  LESS HOSPITAL CENTRIC

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Phase 1 Key area of focus

• Age, frailty and complex needs
• Reducing avoidable admissions and reduce long
  stays in hospital
• Improving the capability and capacity of health
  and social care services in the community to
  support older people

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The approach

• Phase 1 of the Right First Time programme has
  been split into 3 projects which have begun to
  deliver real benefits to patient care and the
  start of the transformation journey across the
  health system.

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Project 1

• Project 1 has focused on the development and
  prototyping of integrated care teams (ICTs) that
  align with the emerging GP Practice Associations,
  enabled by Risk Stratification, Assistive
  Technology and Self Care.

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Project 1 GP Associations

• Discussions around the concept of GP Practice
  Associations have been taking place over the last
  year and practices are now starting to align
  themselves into groups of between 30,000 40,000
  patients with a view to creating more integrated
  working with other Health and Social Care
  resources within the community.
• 16 associations have been identified across the 4
  CCG Localities Hallam and South, Central, West
  and North). The emerging associations have
  started to meet and early discussions have
  identified some opportunities for working
  together.

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Project 1 Integrated care teams

• District Nursing services being aligned around
  the emerging GP Practices associations and these
  will form part of the core of the new integrated
  care teams.
• A reorganisation of the Assessment and Care
  Management Services (SCC) has also taken place
  aligning with GP Practices.
• Further work has now commenced to explore the
  next phase of development for the Integrated Care
  Teams and how they will incorporate Social Care
  activities.
• Initial discussions have also taken place with
  Community Mental Heath and Community Pharmacy to
  try to identify possible links and ways of
  working.

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Project 1 Integrated care teams

• Project 1 is working closely with a number of
  on-going pilots across the city (including Low
  Edges, Batemoor and Jordanthorpe) and supporting
  the development of other prototypes within GP
  Associations, for example the recruitment of
  Community Support Workers to provide the
  interface between Health and Social Care.

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Project 1 Risk stratification

• The combined predictive model of risk
  stratification has been rolled out to 98 of GP
  practices, allowing them to identify patients of
  high and emerging risk of admission to hospital.
• Will enable GPs to then work with other health
  and social care professionals to put
  interventions in place to support these patients.
  
• Further analysis is required to understand what
  actions practices are taking as a result of using
  this tool and impact on patient care and outcomes.

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Project 1 Impact so far

• 95 of the registered population is now risk
  stratified
• Significant alignment in place for primary and
  community services (health and social care)
• Some testing for how Integrated Care Teams could
  work

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Project 2 redesigning the front door

• Project 2 has focussed on redesigning the front
  door response (e.g. Frailty Unit) at STH by
  reducing the number of elderly admissions and by
  completing comprehensive assessments at the point
  of referral and developing consistent thresholds
  for admission.

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Project 2 redesigning the front door

• The development of the Frailty Unit by Sheffield
  Teaching Hospitals at the Northern General
  Hospital was undertaken with support from the The
  Health Foundation and partners across the Right
  First Time partnership.
• All consultant geriatricians at Sheffield
  Teaching Hospitals changed rota pattern to 7 day
  working at the front door from 1stApril 2012.
• The Frailty Unit launched virtually from
  beginning of May and in physical form from
  mid-May.
• There was wider system development in the
  Community under the Right First Time projects
  that facilitated the flow.
• Results from April to September 2012
• Reduction in bed usage by Geriatric medicine
  (medical outliers reduced rather than bed
  closures) by over 60 beds.
• 16 reduction in readmissions
• 13 reduction in raw mortality

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Project 2 crisis prevention

• In conjunction with project 1, project 2 has also
  been developing services to provide better
  response to crises, particularly for
  residential/nursing homes.
• For example the expansion of the falls service
  (the number of interventions rising from 1,682 to
  3,364 in12/13). Q1 data shows falls admissions
  have reduced significantly.

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Project 2 Impact so far

• Early success with reducing some avoidable
  admissions of the frail elderly.
• Improved mortality rates, reduced length of
  hospital stay and reduced readmission rates for
  frail elderly patients who need emergency care.

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Project 3 Impact so far

• Streamlined discharge process for complex
  patients
• Reduced number of patients with long lengths of
  stay
• Fast track process for patients going into long
  term care, though the Sheffield rates are higher
  than average
• Better in reach services for patients with
  dementia

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Phase 2 the plan for the next 3 years

• Broaden the scope to include mental health,
  childrens unscheduled care (in conjunction with
  Future Shapes) and parts of planned care
• Raise the ambition to significantly reduce
  avoidable emergency admissions in the next three
  years (based on achieving an optimally performing
  health and social care system in place).
• Aim for further integration of community services
  to manage the re-alignment of care more
  proactively

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Phase 2 the Plan for the next 3 years

• Public communication and engagement programme
  developed
• Reference group made up of members of the public,
  patients, carers etc. being established
• Oganisational development strategy being
  developed.
• IT strategy being developed

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• Questions