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Principal Community Pathways h Sunderland & South Tyneside

Principal Community Pathways h Sunderland & South Tyneside. A programme to design and implement new, evidence-based community pathways for adults and older people. Our ambition is high and is matched by the expectations of service users and carers. The new pathways will :

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Principal Community Pathways h Sunderland & South Tyneside

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  1. Principal Community PathwayshSunderland & South Tyneside

  2. A programme to design and implement new, evidence-based community pathways for adults and older people. • Our ambition is high and is matched by the expectations of service users and carers. The new pathways will: • Significantly improve quality for the patient • Double current productive time of community services by redesigning current systems • Enhance the skills of our workforce • Improve ways of working and interfaces with partners • Reduce reliance on inpatient beds and enable cost savings • This is not achievable in isolation and to be successful we need it to be part of integrated work with partners Principal Community Pathways

  3. Principal Community Pathways – Timeline Apr 14 July 14 Jan 15 Apr 15 Jan 14 Oct 14 Design Test Implement Pre-engagement Design Test Implement Tranche 1 – Sunderland & South Tyneside Test Pre-engagement Design Implement Tranche 2 – Northumberland & North Tyneside Tranche 3 – Newcastle & Gateshead

  4. What will be different? Our Commitment There will be a single point of access for all referrals Most non urgent services will work from 8am – 8pm, and waiting lists will be minimal Treatment packages will be evidence based and staff will be trained to deliver a broader range of nice recommended interventions Principle of ‘no Bouncing’ Staff will have twice as much time to spend with patients Services will have a recovery focus from day 1. Integrated working will improve the quality of life for service users. Service users will be able to re access services easily and quickly if they need to. Current Experience • There are lots of confusing ways to access services • Most non urgent services operate Monday to Friday 9 – 5, and there are waiting lists • Treatment episodes cannot always be linked to an outcome or a nice guidance recommended treatment, staff often have to refer to others for treatment • Patients can bounce around the system • Staff time is taken up with typing, driving and admin • Patients stay in services for a long time due to lack of joined up working and support to help them recover • Patients don’t want to be discharged because it’s hard to get back into services

  5. Single Point of Access Triage Team Home Based Treatment Assessment Gatekeeping Urgent IRT 11 Single Point of Referral Rapid Response Nurses Triage & Action Clinical Diary Non-complex UCT Routine Clinical Diary Complex Huddle

  6. Sunderland Team Configuration Psychosis and Non-Psychosis Cognitive Learning Disabilities

  7. Psychosis and Non-Psychosis Teams Sunderland x 3 teams South Tyneside x 1 team Psychosis Psychosis EIP EIP Shared Resource Step Up hub Step Up Step Up Non-Psychosis Non Psychosis PD PD Shared Resource Psychosis/Non Psychosis Clinical Leads

  8. Cognitive & Functional Frail Teams Sunderland South Tyneside Community Team Community Team MPS YPD Challenging Behaviour Step-up / Day Service Step-up / Day Service Central Resource Cognitive & Functional Frail Clinical Leads

  9. Learning Disability Teams Sunderland Challenging Behaviour Physical Health Mental Health Learning Disability Clinical Leads

  10. Phased Transition Process May 14 Dec 14 Clinical Risk and Continuity of Care Performance Management Caseload Migration Communication Staffing Future State Current State Safety

  11. Evaluating PCP

  12. Strategic Driver Improve QUALITY for the patient Improved outcomes and effectiveness: Substantially moreevidence-based interventions; recovery focus; care pathways and packages; time well spent with patients Improved experience: patient and carer-centred services; care closer to home in the community; partnership approach; service user and carer involvement in design, collaborative ways of working, easy access and re-access of services Improved environments: good quality venues, accessible locations PCP Benefits Improved outcomes and experience Improved safety Improved flow: Alignment of the pathway across community and inpatient services; fewer admissions; reduced length of stay; better discharge planning; better transitions & partner working; balanced flow of access and discharge Efficient clinical services: New systems and processes; IT revolution; reduced bureaucracy and waste Strategic Driver Reduce COST PCP Benefits Reduced reliance on inpatient beds PCP Benefits Efficient services Strategic Driver SUSTAINABLE services Improved skills: Clinical skills development programme; evidence-based interventions Improved teams and team-working: Aligned to patient need; new systems and processes; MDT working; team resources aligned to demand Willing partners and integrators: This can only work well as part of an aligned whole system PCP Benefits Skilled workforce Partnership and integration

  13. What to expect - the Numbers (adult and older people)

  14. How will we know what difference has been made? Quality and Safety Data Suite Developed by senior clinicians to monitor and measure the impact of transformation across the Trust, designed to answer: • Does the PCP model work? • Have outcomes for patients improved? • Do service users and carers think the service has improved? • Are we delivering more evidence based interventions? • Is there a greater recovery focus leading to reduced reliance on inpatient beds? • Have waiting times reduced? • Are clinicians spending more of their time with patients? • Does the skill mix match demand for services? • Is Transformation safe? • Has there been an impact on out of area referrals? • Has the number of readmissions and re-re-referrals changed? • Are community services contributing to delayed discharges? • Has the average length of stay changed? • What is the impact on community workload? • Has there been an impact on the proportion of incidents? • What has the impact on staff – sickness, morale, vacancy rates?

  15. How will we know what difference has been made? • For Service user and Carers: • Service User led narrative interviews. To be carried out over a longer period of time to assess cultural and behavioural changes including: recovery focus, collaboration, co-production, self-management • Satisfaction with services. To assess service user and carer satisfaction with services as delivered at a point in time • Current feedback sources: Points of You, Family and Friends Question • For Staff: • Staff Wellbeing evaluation. To understand the impact of the model on staff morale and well-being • Satisfaction with services. To assess staff feedback on the PCP model covering efficiency, effectiveness, quality and safety of services • Current feedback sources: Staff Survey, Family and Friends Question • For Partners: • Satisfaction with services. To assess the impact of the model on the range of partners we work with including Commissioners, GPs, Social Care and other health providers. To include ease of access to services, satisfaction with service response as well as overall satisfaction with services

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