1. 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

2. A bit about Leeds West
37k population
37 GP Practices

3. 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

4. NHS England
Avoidable Unplanned Admissions (AUA) direct enhanced service for primary care 1 April /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/ /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

5. 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)

6. 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

7. Community of practice
Established a Care Coordinator Community of Practice: 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)

8. 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

9. 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

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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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?

18. Contact: Karen Newboult Karen.newboult@nhs.net