Right First Time:
Update
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.
Vision
To ensure all Sheffield’s 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.
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
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
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.
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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
Phase 2: the plan for the next 3 years
• Broaden the scope to include mental health, children’s
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
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
Questions