1. Commissioning for Outcomes 7-day services across the community Paul Maubach Chief Accountable Officer Dudley CCG

3. Dudley CCG: context  CCG registered population = 312,000  48 practices  10 single handed practices  Mixture of wards including some in the lowest 20% for most deprived across the country and some in the top 20% of most affluent.

5. Our starting point Population-based healthcare Our CCG is a population-based organisation of c.310,000 registered members A substantial proportion of the national outcome measures are population based: NHS Outcomes Framework Adult Social Care Outcomes Framework Public Health Outcomes Framework CCG Outcomes Indicator Set

6. Deaths by Day in Dudley - 2012 DayMortality (Ave deaths per day) Sunday7.5 Monday7.8 Tuesday7.6 Wednesday7.6 Thursday8.1 Friday8.4 Saturday7.8

7. Local Dudley Service Provider Need not Convenience ‘Our caring, compassionate and highly experienced staff are available 24 hours a day where you can be guaranteed of a personal service from the first call. If you can't get to us don't worry, we will be happy to visit you in the comfort of your own home’

8. A Mutualist Approach Shared Ownership  Each citizen is a registered member Shared Responsibility  Co-production with the individual  Services working together Shared Benefits  Personalised and population outcomes

9. 7 day services: variation in delivery

10.  Post weekend peaks in admissions  Postponement of discharges due to absence of support services – therapy, pharmacy etc..  Unnecessary admissions due to absence of more appropriate primary and community health services  Inconsistency of patient experience and response, 7 days per week 7 Day Response To Avoid…..

11.  Mapping services – moving some to 7 days  Introducing new services – rapid response  Improving infrastructure – standard, mobile IT  Developing community standards  System alignment - to share responsibility  Organisational Development – whole system  New innovation – patient-led outcomes  Commissioning for outcomes 7 day services – Early adopter

12. 7 day services – connection to Integration & Better Care Fund 7 day services Community Rapid Response Team OD: Leadership programme Prevention agenda and tele-health Risk stratification Single point of access Dudley Care Home programme Integrated teams

13. Community Mental Health Teams: adults and older people Palliative care team Heart failure- joint pathway with acute OT Physio Care home nurse practitioners Stroke Neurology Social service teams SLT Current 7 day working From July 2014 Potential to move to 7 days in 2014 MH Crisis Resolution Community Rapid Response Team Tele-care services Dementia Gateways District Nurses Current 7 day working Intermediate Care Community Respiratory Team Virtual ward (Case Managers) Care home provision

14. Evidence base:-  19,500+ over 65 arrived at ED  14,500 admissions over 65  10,000+ over 75  6,500 admitted for 2 days or less  85% arrived by ambulance Community Rapid Response Team

15. Community Rapid Response Team for Older People with Frailty Integrated with Care Home Nurse Practitioners and Social Care Assistants PATIENTS WMAS NHS 111 WMAS NHS 111 GP Out of Hours Community Nursing Teams Assessment by ANP or Care Home Nurse Practitioner Within one hour Assessment by ANP or Care Home Nurse Practitioner Within one hour Step down to Locality Integrated Teams Single Point of Access for Advanced Nurse Practitioner Based at WMAS Single Point of Access for Advanced Nurse Practitioner Based at WMAS Admit to EAU Admit to EAU - Initiate treatment → - Initiate care package → up to 7 days (then review) - Initiate care plan - Initiate treatment → - Initiate care package → up to 7 days (then review) - Initiate care plan

16.  Over 2,200 residents in nursing and residential homes registered with a Dudley GP  High number of urgent care admissions  Dudley Care Home LES operates to provide proactive care and initiate advanced care plans.  Team of 6 care home nurse practitioners to double in size to be integrated with rapid response team and become a 7 day service. Dudley Care Home Programme

17.  Imperative that community practitioners have access to pertinent information and particularly for a 7 day service when practices are closed.  All practices now on EMIS web  Piloting tablet using ‘Inchware’ technology to access medical information remotely including the ANPs Improving Infrastructure: Mobile IT

18.  Identification of risk using ACG tool  MDT Care Planning  Care gap Improving Infrastructure: Risk Stratification

19. 1.Patient experience 2.Integrated team review 3.Information and communication 4.Diagnostics 5.Speed of access and assessment in the community 6.Mental Health 7.Quality Improvement 8.Palliative and End of Life Community Standards

20.  Community nursing and therapy services have a single point of access  Social services have a single point of access  Both in the same building!  Moving to joining together and include mental health Aligning Services: Single point of access

21. Practice integrated teams  GP, pharmacists, community nurses, named social and mental heath workers. To review risk stratification tools; agree a Care Coordinator for complex cases; take shared responsibility for outcomes Locality MDT teams  GP Leadership posts in each locality. Remit of reviewing collective outcomes of all teams in their locality and ensuring pathways to locality to borough wide services function effectively Aligning Services: Integration Model

22.  Dudley Leadership Group (System resilience group)  Vertical authorisation for the work  Change Project Team  Early adopters for our Analytical Network Change Process  Recognises importance of shared responsibility and networked leadership  Information Sharing and Development Days:  New Working Practices to Improve delivery  All front-line staff go through the same induction and development programme  Facilitated Multi-Professional Team Working:  To deliver networked care for their population  Planning how to work together, rather than have imposed top-down solutions OD programme

23. Person GP Practice Community CCG / specialist (hospital ?) teams Registered Member Based in a Locality Part of a System Aligned, Networked Population Health and Wellbeing Services Commissioning for outcomes

24.  From a Representative approach:  Patient perspectives and involvement is standard  To: Fully Participative approach:  Development of systematic tool (PSIAMS) to record the patient experience of care  Enables patient to establish their own outcome goals with the services and chart their progress against them  Includes health and wellbeing as well as social impact outcomes  Piloting with VCSE organisations  being upskilled & changing their practices.  Enables market entry for smaller organisations  Gives us outcome data for every person receiving care Patient-led outcomes

25. Population outcomes  With networked teams operating on the same population basis we can now implement performance management and incentives for population-based outcomes  Practice networks link collectively to the system network  Developing shared outcomes across providers  Both vertically and horizontally  Introducing first set of incentives for 15/16 contracts  Join our working group!

26. A Mutualist Approach Shared Ownership  Each citizen is a registered member Shared Responsibility  Co-production with the individual  Services working together Shared Benefits  Personalised and population outcomes