1. KNOWSLEY CARE CAMPUS WORKFORCE REDESIGN ENGAGEMENT METHODOLOGY Presented by: Julie Holland Date: September 2011

2. Methodology Organisation Development Services Population Centric Model for Workforce Planning (ODS 2008). Skills for Health - Competency Based Planning tools. (SfH 2011) JH/MAY11

3. ODS Model (ODS 2008) JH/MAY11

4. Patient Proxy - Fred & Sonia elderly couple (80+) live in rented accommodation (private tenants) with access difficulties, and poor facilities/amenities and poor transport networks. have five children 3 very supportive 2 estranged. 1 estranged son is the landlord of their home and rent arrangements are difficult. Family dynamics are strained resulting in feuds’, and some complex financial issues. both socially isolated and lonely and have 5 pets to manage. benefit dependent. Sonia has diabetes, angina and epilepsy totally dependent on family for her care following a stroke, and is housebound. communication difficulties (speech) and depressed although mentally bright. Sonia is approaching the end of life and has chronic pain and pressure sores. She is a smoker and occasional drinker. Fred is Sonia’s main carer has rapidly declining health due to neglect. history of COPD, prostate cancer, hypertension and arthritis. struggles to care for Sonia and is often short tempered, stressed and verbally aggressive and is restricted by his wife’s immobility. Fred is an ex-smoker. 4 JH/MAY11

5. SONIA’S NEEDS BE PAIN FREE MONEY WORRIES WOUND TO HEAL TO TALK & BE LISTENED TO FEEL SAFE BE ABLE TO GO OUT HELP HERSELF WORRIED ABOUT DYING 5 JH/MAY11

6. FRED’S NEEDS HELP WITH SONIA MONEY WORRIES TO BE PAIN FREE & ABLE TO BREATHE TO TALK & BE LISTENED TO FEEL SAFE BE ABLE TO GO OUT HELP WITH DOMESTIC WORK WORRIED ABOUT SONIA DYING 6 JH/MAY11

7. SONIA’S NEEDS BE PAIN FREE HFM A2.4 HFM B1.1 HFM B14.2 HFM A2.5 HFM B3.1 HFM B15.1 HFM A2.8 HFM B4.3 HFM B15.6 HFM A2.9 MONEY WORRIES HFM 1.5 HFM B16.4 HFM C2.4 HFM C2.6 WOUND TO HEAL HFM A2.4 HFM B1.1 HFM B4.3 HFM A2.5 HFM B3.1 HFM A2.8 HFM A2.9 HFM B14.2 TO TALK & BE LISTENED TO HFM 1.2 HFM C2.6 HFM 1.4 HFM 6.1 FEEL SAFE HFM 3.5 HFM B16.4 HFM C2.4 HFM C2.6 BE ABLE TO GO OUT HFM 3.5 HFM A2.9 HFM 3.8 HFM B3.1 HFM 6.1 HFM B16.4 HFM C2.4 HELP HERSELF HFM 1.5 HFM B16.4 HFM C2.4 HFM B3.1 HFM C2.1 HFM F4.4 HFM B15.8 HFM C2.2 WORRIED ABOUT DYING HFM 1.5 HFM B18.1 HFM B3.1 HFM C2.6 HFM B14.2 7 JH/MAY11

8. FRED’S NEEDS HELP WITH SONIA HFM 3.8 HFM 6.1 HFM B17 HFM B2.2 HFM C2.6 HFM F4.1 HFM B4.3 HFM C2.4 MONEY WORRIES HFM 1.5 HFM B16.4 HFM C2.4 HFM C2.6 TO BE PAIN FREE & ABLE TO BREATHE HFM A2.4 HFM B1.1 HFM B14.2 HFM A2.5 HFM B3.1 HFM B15.1 HFM A2.8 HFM B4.3 HFM B15.6 HFM A2.9 HFM B15.8 TO TALK & BE LISTENED TO HFM 1.2 HFM C2.6 HFM 1.4 HFM 6.1 FEEL SAFE HFM 3.5 HFM B16.4 HFM C2.4 HFM C2.6 BE ABLE TO GO OUT HFM 3.5 HFM A2.9 HFM 3.8 HFM B3.1 HFM 6.1 HFM B14.2 HELP WITH DOMESTIC WORK HFM 3.8 HFM B16.4 HFM C2.6 HFM 6.1 HFM B17 HFM C2.4 HFM A2.4 WORRIED ABOUT SONIA DYING HFM 1.5 HFM B18.1 HFM B3.1 HFM C2.6 HFM B4.3 HFM B14.2 HFM B18.3 8 JH/MAY11

9. Fred & Sonia’s Needs Competences JH/MAY11 PATIENT PROXYHFMSfH REFERENCE FUNCTIONSfH COMPETENCE SONIA & FRED’S NEED To talk and be listened to. CORE 1 COMMUNICATION HFM 1.2 Communicate effectively CM G4 - Communicate with individuals, groups and communities about promoting their health and wellbeing in a defined caseload HFM 1.2 Communicate effectively CHS48 - Communicate significant news to individuals HFM 1.2 Communicate effectively GEN62 - Collate and communicate health information to individuals HFM 1.2 Communicate effectively GEN97 - Communicate effectively in a healthcare environment HFM 1.4 Develop relationships with individuals HSC233 - Relate to and interact with individuals HFM 1.4 Develop relationships with individuals CHS100 - Develop relationships with individuals with long term conditions CORE 6 EQUALITY & DIVERSITY HFM 6.1 Ensure your own actions support equality of opportunity and diversity HSC234 - Ensure your own actions support the equality, diversity, rights and responsibilities of individuals SPECIFIC C HEALTH PROMOTION C2.6 Act on behalf of an individual, family of community HSC368 - Present individuals' needs and preferences C2.6 Act on behalf of an individual, family of community HSC410 - Advocate with, and on behalf of, individuals, families, carers, groups and communities

10. Knowsley Care Campus Data Collection & Analysis; diagnostics Single Point of Access Referrer Entry: Critical Episode Risk Stratification New patient Step Down From Active Case Management Joint Multi Disciplinary Meeting Eligible for Active Case Management Allocate to Key worker Active Case Management Signpost to Other Services; other pathways P Discharged Deceased GP Specialist Practitioners/Nurses Intermediate Patient Care Third Sector Reablement Family Carers Patient Centred Care Care Co-Ordination Key Worker; Active Monitoring Effective Utilisation of Integrated Resources Promotion of Self Care/ Management Direct Care Step Down Transfer to other care pathways Self Caring No longer risk stratified (return to general practice for routine management Pathway for Critical Episode Clinical Triage STEP 1. STEP 2. STEP 3. STEP 4. STEP 6. STEP 7. STEP 8. STEP 5. STEP 9. CORE WORKFORCE: Assistant Practitioner Community Matron Community Staff Nurse District Nurse Health & Social Care Worker Re-ablement Worker Social Worker 10 JH/MAY11

11. Fred & Sonia’s Care Campus Pathway STEP 1. Fred phones the single point of access requesting an urgent response to Sonia ‘s deteriorating health. STEP 2. Urgent referral process set in motion - practitioner contact within 4 hours. STEP 3. Practitioner reviews Sonia’s existing electronic health records in the community. Urgent response- practitioner visits within 4 hours to assess and address Sonia’s urgent needs. STEP 4. Practitioner presents Sonia & Fred’s current health status and needs to MDT meeting – Case Management agreed. STEP 6. Key worker allocated STEP 7. Active Case Management. Assessment of Sonia & Fred’s needs, intervention, advice, information and review of health & wellbeing. STEP 8. Step down from active Case Management. Sonia & Fred remain on the District Nurse caseload to address Sonia’s pressure area needs. 11 JH/MAY11

12. Fred & Sonia’s Care Campus Competences Patient’s Perspective/Need Service Provider Role/responsibility Health Functional Map SfH Reference Function SfH Competence STEP 1. Sonia’s health is deteriorating. She is experiencing increasing pain. She is unable to sleep. She is placing increasing demands upon Fred that he cannot address. Fred is worried about Sonia and wants help for her. Fred’s health is also deteriorating as he attempts to take care of Sonia. Fred phones the Care Campus phone line to request an urgent response. Fred wants to know how long it will take for someone to visit? STEP 1. Single point of access (SPOA) Call received by Admin staff. Consent sought. Fred listened to and details documented. Specific questions asked from script. Fred reassured and informed that a health practitioner will be with him within 4 hours. Admin staff confirms that they will phone Fred back to inform him who the health practitioner will be. Any immediate relevant advice given. CORE1 COMMUNICATION SPECIFIC B HEALTH INTERVENTIONS CORE 6 EQUALITY & DIVERSITY CORE 1 COMMUNICATION HFM 1.2 Communicate effectively HFM 1.4 Develop relationships with individuals HFM B1.1 Obtain valid consent for interventions or investigations HFM 6.1 Ensure your own actions support equality of opportunity and diversity HFM 1.5 Provide information, help and guidance HFM 1.2 Communicate effectively GEN97 – Communicate effectively in a healthcare environment GEN21 – Interact with individuals using telecommunications HSC233 - Relate to and interact with individuals CHS100 – Develop relationships with individuals with long term conditions CHS167 - Obtain valid consent or authorization HSC234 - Ensure your own actions support the equality, diversity, rights and responsibilities of individuals HSC26 - Support individuals to access and use information HSC21 – Communicate with and complete records for individuals

13. C A R E C A M P U S Step Up/ Step Down Trigger points for patients to access appropriate service and support based on risk factors RISK STRATIFICATION = HIGH RISK STRATIFICATION = V. HIGH Core workforce competences:100 HFM 1.2 HFM 4.6 HFM A2.4 HFM B3 HFM 1.4 HFM 4.7 HFM A2.5 HFM B14 HFM 1.5 HFM 5.1 HFM A2.6 HFM B16 HFM 2.1 HFM 5.2 HFM A2.8 HFM C2 HFM 2.2 HFM 6.1 HFM A2.9 HFM D2 HFM 3.5 HFM A2.1 HFM B1 HFM F4 HFM 3.8 HFM A2.3 HFM B2 High level workforce competences: 17 HFM A2.2 HFM B16.4 HFM A2.3 HFM B17 HFM A2.4 HFM B18.1 HFM B14.2 HFM B18.3 HFM B15.6 HFM C2.5 HFM B15.8 Very High level workforce competences: 4 Skills for Health HFM B4.2 HFM B4.3 HFM B14.1 HFM B15.1 KNOWSLEY CARE CAMPUS WORKFORCE COMPETENCES CORE WORKFORCE: Assistant practitioner. Community Matron. Community Staff Nurse. District Nurse. Health & Social Care Worker. Re-ablement Worker. Social Worker. 13 JH/MAY11

14. References ODS (2008). Organisation Development Services Population Centric Model for Workforce Planning. ODS Skills for Health (2011). Competency Based Planning Tools. SfH