2. STEPPING HILL & VICTORIA NEIGHBOURHOOD ENGAGEMENT WORKSHOP SESSION THREE 6 October 2015 2

3. Purpose To design an approach for the identification of patients requiring complex case management and a pathway for the delivery of multi- disciplinary group management; in Hazel Grove and Offerton and Victoria neighbourhoods. Outcomes Reviewed the outputs from session two together An understanding of the lessons learnt from the Marple and Werneth multi-disciplinary complex case management programme Designed a pathway for the delivery of multi-disciplinary group management in Hazel Grove and Offerton and Victoria neighbourhoods Design an approach for identification of patients needing complex case management in Hazel Grove and Offerton and Victoria neighbourhoods. 3

4. Development phases Core team GPs, DNs, SWs Core team Plus 3 rd sector Core team Plus 3 rd sector Mental Health Core team Plus 3 rd sector, Mental Health, Therapy, Intermediate tier Full new Out of hospital service with prevention, planned and urgent links Plan Do Study Act Plan Do Study Act Plan Do Study Act Plan Do Study Act Plan Do Study Act

5. Conversation 1 Which are the top 3 areas where you would value support from Public Health? List on flip chart paper and be prepared to share with the whole group 5

6. COMPLEX CASE FINDING AND MANAGEMENT: Learning from Marple and Werneth

7. What do we mean by complex? In Marple and Werneth: Any person who is over the age of 18 and is a Stockport resident, a person with a long term condition and one or more of the following will be identified as having complex needs: The person will have been identified as benefiting from a multi-agency approach to support their care. The person has been identified as being at high risk of readmission to hospital The person’s condition, social band or functionality has deteriorated or become unstable However: Many people with multiple conditions are managing well with the support they have Often social circumstances are what makes a case complex – housing issues, debt, isolation, family dynamics Require complex continuous care ‘Layered’ issues Frequently require services from different practitioners Multiple chronic conditions Ability to perform basic daily functions affected Frequent hospitalisations

8. SHARED AIM To wrap care around the needs of people with multiple layers of complex health and social care needs, and their carers. To develop personalised, holistic care and support plans with people to ensure they can live the most independent life possible and stay in the home of their choice. –To anticipate and plan for escalation or deterioration. –To manage their medical illness and social care needs. –To promote self care/management –To agree the plan, and thus its implementation, with the person in the context of their own personal goals

9. CASE FINDING Predictive modelling –Patients at Risk of Readmission - Combined PARR Some appropriate cases, but many that are managing well or appropriately Regular updates work best as list changes quickly Historical data crisis often over by time flag. –Multiple comorbidity Some appropriate cases, but many that are managing well or appropriately Does not change in the same was as PARR –Frailty Other methods –Personal recommendation from hospital from partners – NWAS, Housing, Third sector, Private Providers People making contact at any point in the system that would benefit from other involvement (routine or unplanned face to face, HWB check etc.)

10. CASE SHARING Multi-disciplinary Neighbourhood Service case sharing –Regular meetings – at first –Emails / Telephone calls –By the kettle Case coordinator Consent Everybody’s responsibility to participate by finding and sharing cases Rapid discussion and assessment of need and support Share pertinent information to avoid duplication Understand colleague’s roles, capacity, and skills Trust one another’s judgement and abilities Available to act on what is being asked “I saw Mrs X today... I think she needs support with …..” “Could you give Mr Y a call about ……” “Did you know Mrs Z went into hospital last night…

11. CASE MANAGEMENT Holistic assessment Case coordination Personalised care and support plans that plan for deterioration / escalation Continuous information flows within neighbourhood service, and access to colleague’s support and participation Access to wider support and advice –Pathways for escalation and deterioration that support people in the neighbourhood, and rapid de-escalation to draw people back to neighbourhood support as soon as possible –Locality Practitioner Group Clarity around who owns clinical risk

12. LOCALITY PRACTITIONER GROUP Meeting needs that cannot be met though neighbourhood service support or intervention, by working with partners outside neighbourhood service Joint problem-solving and positively managing risk Participation from professionals that can supply information and act on it –GP Practice staff –NurseSocial worker –Allied health professionalsThird sector –PharmacistMental health –HousingEtc…. Participation can be virtual and case-related – tel/ video conference Preparation by case coordinator and participators in advance Discharge back to mainstream delivery when appropriate, and re- escalate if required.

13. GP ROLES IN COMPLEX CARE Identification of people with complex need (not just GP) Validation of the data from risk stratification Medical element of care planning Medical management Maintaining medical responsibility whist person is in normal place of residence Clinical leadership to the multi-disciplinary meetings Using the model of care as defined

14. KEY QUESTIONS How will you identify appropriate cases? How will you ensure that the most appropriate person deals with the case? How will you prioritise the most appropriate cases? How will you access specialist and borough-wide services when you need them?

15. Conversation 2 How will patients with complex needs be identified? (Each person to brainstorm ideas on post-its & stick on flip chart: 10 mins) Using ideas generated, design a collaborative approach for indentifying patients with complex needs across each of the neighbourhoods (in neighbourhood teams: 20 mins) 15

16. Conversation 3 What are your impressions of the pathway shared? What's missing? What changes should we make? What are the next steps to finalise & agree a pathway for Stepping Hill and Victoria? 16