Commissioning for Outcomes
7-day services across the community
Paul Maubach
Chief Accountable Officer
Dudley CCG
Dudley CCG: context
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CCG registered population = 312,000
48 practices
10 single handed practices
Mixture of wards including some in the lowest
20% for most deprived across the country and
some in the top 20% of most affluent.
Our starting point
Population-based healthcare
Our CCG is a population-based organisation
of c.310,000 registered members
A substantial proportion of the national
outcome measures are population based:
•
•
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NHS Outcomes Framework
Adult Social Care Outcomes Framework
Public Health Outcomes Framework
CCG Outcomes Indicator Set
Deaths by Day in
Dudley - 2012
Day
Mortality
(Ave deaths per day)
Sunday
7.5
Monday
7.8
Tuesday
7.6
Wednesday
7.6
Thursday
8.1
Friday
8.4
Saturday
7.8
Local Dudley
Service Provider
Need not Convenience
‘Our caring, compassionate and highly
experienced staff are available 24 hours a
day where you can be guaranteed of a
personal service from the first call. If you
can't get to us don't worry, we will be
happy to visit you in the comfort of your
own home’
A Mutualist Approach
Shared Ownership
 Each citizen is a registered member
Shared Responsibility
 Co-production with the individual
 Services working together
Shared Benefits
 Personalised and population outcomes
7 day services:
variation in delivery
Average Net flow of Patients (admissions vs discharges)
20
15
10
5
0
Mon
-5
-10
-15
Tue
Wed
Thu
Fri
Sat
Sun
7 Day Response To
Avoid…..
 Post weekend peaks in admissions
 Postponement of discharges due to absence
of support services – therapy, pharmacy etc..
 Unnecessary admissions due to absence of
more appropriate primary and community
health services
 Inconsistency of patient experience and
response, 7 days per week
7 day services – Early
adopter
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Mapping services – moving some to 7 days
Introducing new services – rapid response
Improving infrastructure – standard, mobile IT
Developing community standards
System alignment - to share responsibility
Organisational Development – whole system
New innovation – patient-led outcomes
Commissioning for outcomes
7 day services – connection to
Integration & Better Care Fund
7 day services
Community
Rapid
Response
Team
Integrated
teams
Dudley Care
Home
programme
OD:
Leadership
programme
Prevention
agenda and
tele-health
Single point
of access
Risk
stratification
Community Mental
Health Teams: adults
and older people
Palliative
care team
Heart failurejoint pathway
with acute
Current 7 day working
Community
Respiratory
Team
Care home
nurse
practitioners
MH Crisis
Resolution
District
Nurses
Current
7 day
working
Dementia
Gateways
Stroke
Intermediate
Care
Community
Rapid
Response
Team
From July 2014
Potential to move to 7
days in 2014
Care home
provision
Tele-care
services
OT
Virtual
ward (Case
Managers)
Physio
Neurology
SLT
Social
service
teams
Community Rapid
Response Team
Evidence base: 19,500+ over 65 arrived at ED
 14,500 admissions over 65
 10,000+ over 75
 6,500 admitted for 2 days or less
 85% arrived by ambulance
Community Rapid Response Team for Older
People with Frailty
Integrated with Care Home Nurse Practitioners
and Social Care Assistants
PATIENTS
WMAS
GP
Out of Hours
NHS 111
Community
Nursing Teams
Single Point of Access for
Advanced Nurse
Practitioner
Based at WMAS
Assessment by ANP or Care Home Nurse Practitioner
Within one hour
Admit to
EAU
- Initiate treatment →
- Initiate care package → up to 7 days (then review)
- Initiate care plan
Step down to Locality Integrated Teams
Dudley Care Home
Programme
 Over 2,200 residents in nursing and residential
homes registered with a Dudley GP
 High number of urgent care admissions
 Dudley Care Home LES operates to provide
proactive care and initiate advanced care
plans.
 Team of 6 care home nurse practitioners to
double in size to be integrated with rapid
response team and become a 7 day service.
Improving Infrastructure:
Mobile IT
 Imperative that community practitioners have
access to pertinent information and
particularly for a 7 day service when practices
are closed.
 All practices now on EMIS web
 Piloting tablet using ‘Inchware’ technology to
access medical information remotely including
the ANPs
Improving Infrastructure:
Risk Stratification
 Identification of risk using ACG tool
 MDT Care Planning
 Care gap
Number of admissions / attendances in following
year
9.00
8.00
Actual Avg no FHS
7.00
Actual Avg no OPAs
6.00
5.00
Actual Avg no AE
Attendences
4.00
3.00
2.00
1.00
0.00
ACG Probability of Future High Cost
Community Standards
1.
2.
3.
4.
5.
Patient experience
Integrated team review
Information and communication
Diagnostics
Speed of access and assessment in the
community
6. Mental Health
7. Quality Improvement
8. Palliative and End of Life
Aligning Services:
Single point of access
 Community nursing and therapy services have
a single point of access
 Social services have a single point of access
 Both in the same building!
 Moving to joining together and include mental
health
Aligning Services:
Integration Model
Practice integrated teams
 GP, pharmacists, community
nurses, named social and
mental heath workers. To
review risk stratification tools;
agree a Care Coordinator for
complex cases; take shared
responsibility for outcomes
Locality MDT teams
 GP Leadership posts in each
locality. Remit of reviewing
collective outcomes of all teams
in their locality and ensuring
pathways to locality to borough
wide services function
effectively
OD programme
 Dudley Leadership Group (System resilience group)
 Vertical authorisation for the work
 Change Project Team
 Early adopters for our Analytical Network Change Process
 Recognises importance of shared responsibility and networked leadership
 Information Sharing and Development Days:
 New Working Practices to Improve delivery
 All front-line staff go through the same induction and development programme
 Facilitated Multi-Professional Team Working:
 To deliver networked care for their population
 Planning how to work together, rather than have imposed top-down solutions
Commissioning for outcomes
Registered Member
Person
Based in a Locality
GP
Practice
Part of a System
Community
CCG / specialist
(hospital ?)
teams
Aligned, Networked Population Health and Wellbeing Services
Patient-led outcomes
 From a Representative approach:
 Patient perspectives and involvement is standard
 To: Fully Participative approach:
 Development of systematic tool (PSIAMS) to record the patient
experience of care
 Enables patient to establish their own outcome goals with the
services and chart their progress against them
 Includes health and wellbeing as well as social impact outcomes
 Piloting with VCSE organisations
 being upskilled & changing their practices.
 Enables market entry for smaller organisations
 Gives us outcome data for every person receiving care
Population outcomes
 With networked teams operating on the same
population basis we can now implement
performance management and incentives for
population-based outcomes
 Practice networks link collectively to the system
network
 Developing shared outcomes across providers
 Both vertically and horizontally
 Introducing first set of incentives for 15/16
contracts
 Join our working group!
A Mutualist Approach
Shared Ownership
 Each citizen is a registered member
Shared Responsibility
 Co-production with the individual
 Services working together
Shared Benefits
 Personalised and population outcomes