Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CENTRAL SUTTON COLLABORATIVE ACE UPDATE – March 2015 ACE PLUS Birmingham Cross City CCG has recently been awarded some additional non-recurrent funding from NHS England for the achievement of a range of Quality Premium targets that were jointly agreed between the CCG and NHS England for 2013/14. As the hard work of the practices in the CCG played a significant contribution in achieving the CCG Quality Premium, and they felt it is only fair that practices are able to develop proposals to invest this money in better care for their patients. This funding is non-recurrent for 12 months and has been termed ‘ACE Plus’ and is to be used for schemes that go beyond the requirements of ACE Excellence. Practices were asked to put forward proposals that could demonstrate delivery of services that were over and above what is required as part of the ACE Foundation, ACE Excellence and Enhanced service schemes. Central Sutton Collaborative put forward two bids and we are pleased to say that we were informed early in March 2015 that we were successful with both bids. Below is a brief outline of the projects we put forward which we are now in the process of developing and implementing over the next 12 months. Overview Project 1 – A 1.5 whole time equivalent Integrated Community Nurse The first proposal from Central Sutton Collaborative was to develop 1.5 whole time equivalent community nurse role/s with the purpose of implementing, developing and supporting a service which meets the needs older or vulnerable people who require support. To provide a targeted support service that is needs led. Our aim is to identify vulnerable people and be pro-active in giving them better access to support over and above the GP care and to support them to live independently. Frail, elderly - >75 Housebound Dementia patients & their carers Cancer survivor support – patients with continuing needs, who are no longer on GSF register. Elderly, recently bereaved if appropriate need identified Birmingham Community Healthcare Trust (BCHCT) are keen to work with us on this pilot and have offered to employ an individual/individuals with the necessary skills and expertise to deliver and develop the pilot. The Collaborative would sub-contract at the agreed rate in line with experience and job description. The overriding purpose of the post would be to develop, promote and deliver an integrated approach to support older people in their homes, at the same time feeding into existing good practice e.g. Assertive Case Manager, District Nursing services and also complement and dovetail with statutory and voluntary organisations. We feel that this is an exciting opportunity for our practices to work collaboratively with BCHCT to rationalise care in the home across the member practices. TARGET GROUPS / NUMBER OF PATIENTS EXPECTED TO BENEFIT Practice Manor Sutton Park Vesey Housebound 91 40 45 Dementia 116 33 56 >75 1406 691 1003 Cancer Care 71 41 92 SCOPE OF CHANGE We are confident that this pilot will enhance the quality of life and promote a more independent culture for the elderly and other targeted groups who need some level of help and enable them to make informed choice about their home, support services and care needs. Working with senior experienced community nurses will best enable us to work closer with hospital and community and social care teams and we will look to streamline related work (e.g. Unplanned Admissions Enhanced Service and Transforming Elderly Care) to prevent duplication of effort and improve effectiveness. Objectives: To reduce unplanned admissions, re-admissions, length of stay and to facilitate early discharges for our vulnerable patients. Enable vulnerable and frail to access all available support including signposting to the third sector To promote healthy minds and living by tackling loneliness, depression, despair and unhealthy lifestyles Identify OT / household risks Enhanced memory problem management – even before dementia Promote / facilitate good financial management – we believe many elderly could benefit from financial review and could signpost to families and third sector. Connect and facilitate community support Engage, involve and expand practice Participation Groups Engage, support and work with current community team and enable development of care but with potential to carry across to other potential service development. More effective setting up of care packages to support people at home Early intervention and preventative support Improve satisfaction with primary care provision Overview - Project 2 – Improving health and wellbeing outcomes for cancer survivors discharged from secondary care. The provision for cancer survivors would be from within the three practices existing staffing structure. There is good evidence from schemes piloted and run nationally by Macmillan Cancer Support that practice nurses are well placed to provide on-going care for cancer survivors building on the existing relationships they have with these patients and taking into account the evolving role of practice nurses in managing long term conditions. One of the practice GP's (Dr Garbutt, Vesey Practice) works with Macmillan Cancer Support and has recently delivered such training to ten / eleven Practice Nurses in Solihull. There is existing work with secondary care on changing communication to provide treatment summaries at the end of cancer treatment detailing follow up arrangements, potential late effects, red flags for recurrence and re-referral and who patients should contact with problems. This is coming on stream now for some hospital sites and we are keen for our ACE group to provide the first local opportunity to fully join up cancer care in this way. The service focuses on providing individualised advice based on patient need, not tumour site, as recommended in NCSI Vision document (Department of Health 2010). Patients at the end of primary treatment will be invited to the practice for a 20-30 minute appointment with a suitably trained nurse. Lists of potential concerns (provided by Macmillan) can be used to outline patient concerns for discussion. The scope of the review would be Identify unmet psychological need Identify and manage consequences of treatment Identify and manage issues specific to the cancer survivor population – fatigue, increased cardiovascular risk and osteoporosis Signposting to lifestyle improvement with particular focus on appropriate exercise programmes, smoking cessation, weight management and vocational rehabilitation (one third of employed patients with cancer are not working 12 months after diagnosis). This will provide for all five domains of the NHS Outcomes framework (prevent people dying prematurely), enhance quality of life for people with long-term conditions, help people recover from an episode of ill-health, ensure positive experience of care and preventing avoidable harm. It will provide the middle three stages of the National Cancer Survivorship Initiative’s framework for improving outcomes: promoting recovery, sustaining recovery and managing consequences of treatment (the first, ‘information at point of diagnosis and supporting active and advanced disease’, lie without the scope of this service or are already provided for). This offer will be made to all patients over 16 on completion of first line cancer treatment (‘remission’). Patients with advanced / metastatic disease are already provided for, for example in practice GSF systems. March 2015