Thanks to Sarah De Biase Yorkshire & Humber AHSN Improvement Academy Developing the role of primary care Clinical Care Coordinators Leeds West CCG Karen Newboult Primary Care Locality Manager Leeds West CCG Thanks to Sarah De Biase Yorkshire & Humber AHSN Improvement Academy

A bit about Leeds West 37k population 37 GP Practices

Primary Care Transformation & Integration 2014 Context Primary Care Transformation & Integration 2014 Ageing population, Increased multimorbidity & frailty Older people majority users of many health & social care services; frequently need to move between services & organisations Need for better integration health & social care - GP practices traditionally work in isolation; interface with other providers of health care on an individual basis

NHS England Avoidable Unplanned Admissions (AUA) direct enhanced service for primary care 1 April 2014 -2016/17 Most ‘at risk’ practice population to have proactive co-produced care plan (top 2%) placed additional processes on primary care didn’t account for the time/skills needed to effectively undertake pro-active case management Everyone Counts – Planning for Patients 2014/15-2018/19: CCGs expected to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so This funding should be at around £5 per head of population for each practice

Leeds West CCG Funded additional nurse time – each practice to have an identified clinical care coordinator Clinical Care Coordinators (CCC): Hosted by primary care Fill the gaps within individual practices Enable pro-active case management Link out into the community Working closely with the Integrated Neighbourhood Teams (INT)

Care Co-ordinators (CCC) 31 practices participating Aims: Supporting patients to stay out of hospital Improving relationships between community teams and GP practice Point of contact for patients carers and other community services Facilitated by a Community of Practice approach Supporting timely discharge from hospital

Community of practice Established a Care Coordinator Community of Practice: http://ia-cocreationnetwork.com/communities/care-coordination-in-primary-care-1795866882 CCC events monthly - CCCs & wider integrated neighbourhood team members come together to sharing & to problem solve challenges encountered in wider ecosystem Staff development: introduction to quality improvement (all); prescribers courses - basic equipment (select few) ; phlebotomy (select few), Year of Care – care planning LTCs (select few)

Case finding - no one size fits all approach Different clinical systems: SystmOne & EMISWeb CCG risk stratification tool identifies top 2% ‘at risk’ for AUA register Other case finding tools available: ACG Systems and/or electronic Frailty Index Further drilling down i.e. by age (>80 year old) or risk profile Case finding / referrals between GPs, Community Matrons, Neighbourhood Team Coordinator Needs based approach: anxiety, recent discharge, dementia, falls history, recent bereavement Inclusion of patients < 75 years old

CCCs Emerging Models Four models emerging: Joint funding across a number of practices to employ a multiskilled team Funding added from other sources to employ Community matron/ advanced nurse practitioner Practice nurse increased hours Experienced Health Care Assistant supported by practice team Experienced administrator with knowledge of local community supported by clinical team Unique & Nuanced

Patient Satisfaction Q2: Do you have a named Clinical Care Coordinator who co-ordinates your care and support? Ttl responses for 5 practices = 77

What do patients say about their care co-ordinator? Her role is very important because she is different to that of a Doctor, she covers a wide range of topics with no time limitations. We all felt reassured after her visit and know who to contact if we have any other problems. Knowing the same people would be visiting Jim each time gave Jim the ability to build up a relationship and trust in what they were doing, Professionals were a joy to welcome into our home I had to deliberate often whether to call out a Doctor which put me under immense pressure now if I have any worries about my mum’s health I can just ring our care co-ordinator and she will advise me’ I feel like I have been thrown a lifeline.

Challenges Establishing momentum Maintaining enthusiasm Varied skill set Buy in at all levels Multiple initiatives all to improve ‘patient flow’ Collecting and analysing data Different clinical systems Marketing the role Full practice commitment Short term funding Primary care transformation- complicating the land scape

Key Achievements Community of Practice Increased knowledge of what the community has to offer Point of contact for outside agencies Examples of ‘new ways of working’ Care Coordinators valued in the wider community Peer support Problem solving Staff development Community of Practice: GPs, CCG employees, INT Coordinators invited to the monthly events Regular sharing from professions within the wider health & social care ecosystem e.g. Adult Social Care, Dementia Support Workers Solution focused – data extraction Test out new approaches – Adult Social Care Data collection methods developed Increased knowledge of what the community has to offer - CCC linking with local community groups; proximity of the CCCs to the GP Practice & close relationships with Neighbourhood team Coordinators Point of contact for outside agencies: forming a bridge and linking GP Practice to what the community has on offer Care Coordinators valued in the wider community i.e. at MDT meetings, sign posting resource for other professionals Peer support extended beyond confines of monthly CoP events i.e. smaller groups working together to problem solve Problem solving: CoP allows for sharing tactic knowledge, good practice & reach consensus on how to do things (care planning approach)/address challenges (build searches for measurement) Staff development - quality improvement methodology, measurement for improvement

How support the communities of practice to progress Patient stories/narratives Modify measures to reflect variation Individual CCC impact case studies and examples of new ways of working Support locality networks as they develop within new models of care Develop networks across Hospital and community

How support the communities of practice to progress Patient stories/narratives Modify measures to reflect variation Individual CCC impact case studies and examples of new ways of working Support locality networks as they develop within new models of care Develop networks across Hospital and community

What needs to happen next? How do CCCs relate to each other and handle change? How best can we identify opportunities which lead to action? How discover what is important for patients? Does the CoP support relations and change? Is there another way? What support is needed – from CCG, from me, from others?

Contact: Karen Newboult Karen.newboult@nhs.net