Download ACE Team Briefing - March 2015

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:
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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