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Programme Overview

Programme Overview. CCG will co-commissioned using Chris and Melanie as Chair of Vanguard sub-group of CCE with delegated Authority and SFI compliance CCG will produce PMO Spec to contract WW to run a series of projects at Hub level (similar to CCCTF) PMO (funds allocated directly to WW)

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Programme Overview

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  1. Programme Overview • CCG will co-commissioned using Chris and Melanie as Chair of Vanguard sub-group of CCE with delegated Authority and SFI compliance • CCG will produce PMO Spec to contract WW to run a series of projects at Hub level (similar to CCCTF) • PMO (funds allocated directly to WW) • Non-PMO (CCG) • WW to produce: • PID (as per CCCTF) • Project outlines • Project Plan

  2. Programme Overview Yorkshire and Humber AHSN Digital Health and Wellbeing Ecosystem launch Multi-specialty Community Provider Vanguard Integrated Care David Haslewood, Programme Manager West Wakefield Health & Wellbeing • CCG will co-commissioned using Chris and Melanie as Chair of Vanguard sub-group of CCE with delegated Authority and SFI compliance • CCG will produce PMO Spec to contract WW to run a series of projects at Hub level (similar to CCCTF) • PMO (funds allocated directly to WW) • Non-PMO (CCG) • WW to produce: • PID (as per CCCTF) • Project outlines • Project Plan

  3. GP Networks & Connecting Care Teams Central Connecting Care Team Networks 3,5 & 6 East Connecting Care Team Networks 1,4 & 7 South East Connecting Care Team Network 2

  4. The Hypotheses 50% of work done by GPs could be carried out by a more cost effective resource We have devised 90 logic models with which to evaluate the programme and test these hypotheses. The new model of care must also achieve the three objectives of the Triple Aim. 30% of elderly people admitted to hospital acutely for a short stay of between 0 and 5 days do not need to be admitted and could be cared for differently in an alternative setting THE TRIPLE AIM 30% of patients occupying an acute hospital bed do not need to be there because their episode of acute care is over

  5. Programme Vision “Through expanded primary care, proactive teamwork and new technology to deliver health and social care at scale to the GP registered list of West Wakefield” Connecting Care Prime Minister’s Challenge on GP Access • Schools App Challenge • Oral Health • Fluoride Varnish • Flouridation • Joint consent • Childhood Obesity • Mental Health • Digital • Service Directory • Symptom Checkers • App Library • Big White Wall • Patient Education • Expert Patients • Care Planning • Social Prescribing • Micro-commissioning • Care Navigators • Phone, Email, Chat, Web • ‘Apple Store’ • Kiosks • Care Navigation App 7-day service Physiotherapy First Pharmacy First Pharmacist in GP Social Worker Mental Health Worker Triage Video Consultations E-Messaging Shared visiting service Integrated Multi-Professional Community Teams inc Nursing, Carers and VCS Information Hub Proactive Care Connected Home Shared records: Citizen-held care record Intensive Home-Based Therapy For physical and mental health Intermediate Tier Beds in Community HealthPod Care Home Project Primary Care Champions Consultants in the Community: Elderly, Cardiology, Respiratory, Mental Health

  6. Integrated Care • Continued development of integrated community teams to further enhance the combined skills of different professionals including physical health, mental health and social care. • Re-design of the specific interface of Community and Practice Nursing to provide an enhanced workforce model fit for the future. • Services to provide care to patients in and closer to their homes utilising community consultants and integrated community teams. • Collaborative re-design of pathways to improve access, effectiveness and efficiency alongside enhanced communication and proactive care targeted with risk stratification and care planning that impacts favourably on admission rates and length of stay. • Development of 24/7 technological connectivity to allow those most at risk to feel more secure and receive early proactive management. • All coordinated through a Command and Control Centre approach which can deploy tactical teams to proactively assist patients to prevent admission as well as support earlier discharge following admission and reduce length of stay.

  7. Hub Development – Waterton House Provider Alliance: MYT, SWYPFT, WMDC, WDH, Nova (all VCS), Age UK, YAS (111,999), LCD, Spectrum Central Hub Waterton House Nursing United Carers Framework Integrated Teams Integrated Teams Call Centre Care Homes Video, E-messaging C3 Ops Centre Consultants Extended Hours GP Admissions avoidance Pharmacy First Connected Home Improved Access HealthPod Physio First Care Navigation Assistive Technology Early Supported Discharge Social Prescribing Unified Communications Digital self-care Federation & Collaboration Citizen-held care record

  8. Information ‘Fusion’ GP System Notifications Housing Comms Link A&E Metrics & Notifications Community Notifications GP System Population Data Fire Comms Link Hospital Admissions Met Office Ambulance Service Hospital In-patient Status Local Authority Records Police Comms Link Smart Home Notifications Public Health Statistics Mental Health Records Informs the Integrated MDT

  9. Integrated MDT Care Navigator Pharmacist Hub Clinical Lead Hub Manager Elderly Care Consultant Therapists Community Matron Specialist Nursing Teams Community Mental Health Nurse Social Worker Community Psychiatrist Community Cardiologist Community Paediatrician Respiratory Consultant Health Visitor Community Nurse Authority to act Co-located Shared mission Daily virtual meeting Shared culture Proactive approach Shared records Mutual trust 24/7 Information Hub Access Generates Care Package Tactical Teams Strategic View GP Practice Nurse

  10. CrossLead • The McChrystal Group is a leadership and management consultancy composed of a diverse mix of professionals from the military, academic, business, and technology sectors. Their consultants specialise in transforming organisations into cohesive, adaptable “teams of teams”. • Drawing from shared experiences transforming the US counter-terrorism apparatus into a high-performing team, McChrystal Group developed the CrossLead leadership and management system to drive the adaptability of small teams at the enterprise level. • As part of a disruptive innovation approach West Wakefield will utilise the services of the McChrystal Group to provide a 1.5-day event for select senior executive from across the Wakefield health and social care economy on the 21 and 22 January 2016. • Approach has been endorsed by Simon Stevens, Chief Exec NHS England, who has challenged Dr Chris Jones to identify 3 to 4 additional sites (Vanguard and Non-Vanguards) across England to replicate the event. • Potential funding available from NMOC.

  11. Programme Overview • CCG will co-commissioned using Chris and Melanie as Chair of Vanguard sub-group of CCE with delegated Authority and SFI compliance • CCG will produce PMO Spec to contract WW to run a series of projects at Hub level (similar to CCCTF) • PMO (funds allocated directly to WW) • Non-PMO (CCG) • WW to produce: • PID (as per CCCTF) • Project outlines • Project Plan

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