Community Team +

1. Community Team + The story so far…….

2. How well does the system currently respond to citizens with complex needs ? (CHECK)How might we better respond to citizens through a holistic approach mobilising the efforts of a broad range of agencies? (PLAN) Two phases of work…t

3. The team We assembled a core team covering all partner agencies, we had: • Occupational Therapists • Social Workers • TelecareCoordinator • GP Practice Manager • Housing Scheme Coordinator • Project Manager • District Nurse • Community Matron • Community Support Manager • Revival Hope improvement Case Worker • ASC Strategic Manager

4. Where We Went Shelton Primary Care Centre University Hospital of North Staffordshire A & E Community Health Services – (District Nurse, OT) Social Care Community Beds Contact Centre Walk-in Centre Single Point of Care

5. The Story of ‘B’…… Social Care UHNS GP DRT Telecare ILCT Partner-ship Trust

6. B – vital statistics….. Over the a 2 year period… 7- different agencies involved 30- different teams or professionals gave input 162- acute/sub-acute beds days consumed 72- (at least) of these were ‘excess’ bed days 66- assessments undertaken 869- telecare interventions

7. Assessments and Referrals? Total Assessments B Total No. of assessments - 74 Different assessment types - 29 Causing Failure and Waste?

8. What matters to ‘B’ ‘I don’t want to go to bed at 9pm I want to watch films’ ‘I really don’t want to go into hospital or residential care’ ‘I want to go out and about, but I’ve been told to stay in this chair’ ‘She dumped me last week, she doesn’t like me like this’ Purpose: ‘Help me live the life I want to lead’

9. Learning from mapping ‘B’ The system doesn’t adapt standard processes Get it sorted, get it closed We focus on doing our own bit Referral system is so complex Difficult to build relationships We focus on freeing up beds, not restoring function We have an episodic culture Assess/Do/Review/Close We focus on targets We assess & refer then assume its dealt with Limited line of sight Focus on protecting my budget

10. What does the system look like from the citizen’s perspective? Close Exit Not me/ Not here Do I need help! Screen Refer Assess Sys tem I’ve had all these assessments and my problem still isn’t sorted!

11. And the cost…..? a year of care During the most recent full calendar year: • Cost the whole system at least £38K (but consider the additional value of B’s brother and sister-in-law’s support) During year of care April 11 to March 12: • 236th most costly patient out of 107,000 • just one of 2,145 patients who cost Health providers at least £20K a year

12. Exceptional / Unlucky?? • Other professionals say they all know a number of B’s….. • ‘B’ only the 12th highest user of the Telecare service • WMAS state B ‘not on their radar’ as a high intensity user • Analysis of 10 patient journeys/cohort of assessments for Hospital Discharge reveals common themes of: • Warning signs not recognised/acted on • Limited lines of sight • ‘Pass the parcel’/not my role • Difficulty accessing the right help at the right time • Service shaped assessments and provision – that miss the point • Analysis of ASC referrals suggest a ‘weak’ approach to prevention.

13. The Opportunity…… • Effectively addressing what matters to B and addressing primary sources of waste1 could have saved £10k (25%) during his most recent YoC • Extrapolated across the cohort of 1700 service users costing 20 to 40k per annum2, an average saving of only15% would generate £6.9 millionper annum (including tier 5 = £15 million) • Addressing system inefficiencies could offer further financial benefits • Avoidable admissions/bed days whilst waiting for a PoC; ambulance call outs; telecare activity • From the Apr 2011 – Mar 2012 LTC YoC data

14. So what happened when we started to do things differently? Feedback from Plan

15. Starting with understanding …..for some we need to stabilise the situation before being able to help…. The presenting ‘what matters’ is not always as important as first appears, but….. Understand what matters Help …..it can help the citizen and us understand ‘what really matters’. …but delivering help allows us to further understand ‘what really matters’

16. ‘Finding’ people was hard…… Triangle of complexity / need ‘J’ ‘M’ ‘z’ ‘X’ ‘C’ ‘Y’ ‘T’ Low to high ‘JL’ ‘MB’

17. Case study Z – a Frequent Flyer

18. The Burns Curve ‘Z’ starts to wobble- Eventual Cancer diagnosis Living well, delivering what matters Today April 10 June 11 November 11 May 12 December 10 May 10 January 11 November 12 January 12 Historical consumption 2010 0 bed days 4 A&E costing £388.07 2011 2 bed days costing £1799.48 3 A&E costing £259.62 2012 38 bed days costing £9,803.50 8 A&E costing £1122.45 2013 - on going 41 bed days costing £14,749.00 6 A&E costing £822.48 October 12 January 13 February 13 December 12 Blockages March 13 April 13 C+ Intervention point Multiple missed opportunities before intervention = UHNS stays = A&E attendances Deterioration or premature death

19. What matters to ‘Z’ Understand ‘What Matters’ Arranged ‘day sit’ to avoid admission Traced daughter Arranged urgent medications Empowered daughter regarding palliative care Purchased clothes, food, fruit etc…. Made home environment safe, clean and accessible Help & Problem Solve Facilitated C Health Care (CHC) funding Arranged a haircut! Arranged fast-track Benefits review

20. But for our intervention…? Situation at home was inherently risky – he could have come to serious harm at any point – fire/exacerbation of COPD. But this aside…… Robust plan for COPD/CA management may not have been put in place = further exacerbations/hospital admissions • Clare to do An appropriate support solution may not have been found so early He would not have stopped smoking so soon His psychological/emotional/familial issues may not have been addressed in time for a ‘good’ End of Life • SYSTEMS BENEFITS • Timely funding and placement finding – due to time invested ‘up front’ and good understanding of Z – 10 to 14 bed days saved? • Improved management of clinical condition = more appropriate resource utilisation

21. Economic impact Note acute costs stabilisation Intervention with ‘Z’

22. PLAN was hard (TREACLE, CULTURE etc …) but we learnt… From the service users point of view – this approach works! This will give us a true understanding of demand and commissioning requirements We are starting to understand workforce/skills requirements We can see opportunities for more appropriate/sustainable resource utilisation For our people – this is liberating, inspiring, more meaningful

23. The ‘Good Stuff’ – Customer feedback You have given me faith in the system again I know you’ll do your best for me Before CT+ I wasn’t living, I was existing ‘I know if I struggle or feel down or need a chat I can just pick up the telephone’ I was raving mad in my flat. Look at me now! You’ve put my mind at rest People have helped give me reassurance. I now feel cared for I wanted a tidy up, not a make-over! I thought I was going to die in a hospital bed when I didn’t want to I don’t usually ask for help but with you I can…

24. We can start to build a rational model based on proper understanding…..

25. ‘What matters‘ compendium Clinical – understanding condition & meds Carers & their wellbeing

26. Blockages Encountered – T&F Treacle log (or what we need to fix…)

27. What We Learnt About Skills The skills we will need….

28. The ‘Good’ Stuff – Our Staff People have boundless energy when set free to make a difference. I have developed new skills and grown in confidence! This approach focuses on ‘what matters’ people and appropriate use of funds Understanding what matters takes more time upfront but is well worth it! How you think something is very different than how it really is… Doing good things is also more efficient

29. Where next????