Encompass Multispeciality Community Provider Dr John Ribchester, Chair and Clinical Lead, Encompass @KMHealthandcare #KMconf2017 ww.slido.com #KMconf2017
Encompass Multi-Specialty Community Provider (MCP) Partnership New models of care 31 October 2017
Community Hub Operating Centres (CHOCs) Five CHOCs – 175,405 patients 2 Whitstable practices 38,574 2 Faversham practices 31,143 3 Sandwich & Ash practices – 17,444 3 Canterbury N 3 Canterbury S practices – 41,612 practices – 46,632
Encompass MCP Journey Phase 1 Phase 2 Phase 3 Phase 5 Phase 4 Integrated Accountable Ramping Encompass Refining Case Care the pace Alliance our model Management Partnerships April to April 2017 August to November October 2017 September October 2016 2016 to 2017 March 2017 Embedding Becoming an Refinement Ramp up of Development the value Integrated and model at scale of the formal proposition Accountable development and pace alliance with and 10 week of whole partner Care proof of model organisations Partnership concept
New models of care Registered Acute populations expenditure on emergency admissions Integrated case Our approach to management each of the population segments Health condition management Supported self-care
Integrated case management Our approach For individuals at high risk of future emergency admission to hospital. Patients may have one or more of these indicators: • Complex co-morbidities • Over 75s • At risk of admissions to A&E in next six months. Care plan • Increasingly dependent on the health and care system. • The patient has underlying social and wellbeing needs not being addressed . Agreed with They are identified through a combination patient/carer of risk stratification and clinical judgement . This builds relationships between health and social care professionals, improves health and wellbeing outcomes and enables multi-disciplinary team (MDT) working.
Our workforce CHOC core team includes: Our Integrated Case Social Care Health and social Management (ICM) Approach representative / social care coordinator worker Pharmacist Mental Health worker GP Social Prescribing Clinical Services Care plan Community nurse Nurse Specialist / LTC Nurse Geriatrician Agreed with Administrator patient/carer Allied Health Professional Integrated Acute Fire and Discharge Police specialists rescue Team Additional members which vary locally:
Health condition management We want to support and empower people who have long-term physical and mental health conditions to keep people well and avoid hospital admission. Moving some services , historically Providing fast access to provided in a hospital, into the services in the community, extending roles of GPs community to avoid and other healthcare professionals. attendance at A&E. Provision of specialist clinics in a community setting, Fourth priority for cardiology, respiratory/pneumonia, Catheter rheumatology and frailty. Service Making sure mental health is given opened in June the same level importance as 2017 physical health. Dementia support worker in place Group psycho-education showing positive results
Supported self care Supporting people to make healthier lifestyle choices to avoid preventable diseases. The aim: • building strong social networks • exercising more • eating more healthily • feeling more supported and in control of lives • reduction in healthcare interventions for patients identified with a social prescribing need
Supported self care Helping people Health trainers make informed roll out across decisions about all CHOCs their health Social prescribing gaining real momentum in year three Waitless Live MIU and A&E An initiative in schools to keep waiting times in east Kent children active Health Help Now Symptom advice and guidance on treatment
Activity deflections ‘First time in years I feel What our confident enough to go 24.7% outside and hang my Catheter patients said washing on the line.’ related admissions ‘I have gained a lot of insight about a condition ‘I’m more confident 27.3% I have had for 17 years.’ and independent. It’s changed my life.’ Short stay admissions “This app is so good. I broke my leg and needed it checked immediately 5.8% and it told me what hospital had A&E minor quicker service and how long it will attendance be to wait – excellent”. 5.7% £3.4m Emergency admissions planned model forecast 2017/18 net savings
And others… ‘Working within the CHOC MDT has improved delivery of person centred care . CHOC facilitates improved working relationships between health, social care and the voluntary sector and identifies gaps in a patient’s pathway that can lead to potential crisis. This is a meeting where all voices are heard , with no hierarchy. CHOC meetings are not only about meeting patient need and responding proactively , they are also a useful forum for sharing best practice , discussing potential outcomes and evaluating Sheila O’Riordan pathways of care. Consultant Geriatrician They are indeed a weekly highlight and I look tells us how she loves social forward to being part of its on-going evolution.’ prescribing #way ahead @RedZebraCommSol Long Term Conditions Lead Nurse @FutureNHS @NHSImprovement ‘Hats off to you, really good meeting and really good progress.’ New Care Models Programme Director NHS England
Replicability and spread Strategic development • Kent and Medway ST • East Kent • Encompass and NHS Canterbury and Coastal CCG • Strategic and operational alliance
Contact us Website: www.encompass-mcp.co.uk Twitter: @encompassmcp Dr John Ribchester – Encompass Chair and Clinical Lead john.ribchester@nhs.net Cathy Bellman – Strategic Project Manager cathy.bellman@nhs.net
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