Part Public Paper 8 Cover Sheet: Governing Body Date Wednesday 2nd July 2014 Title of paper Ealing ICE Review Report Presenter & Organisation Avani Devkaran/Usha Prema Author Ealing ICE Review Steering Group Responsible Director Kathryn Magson Clinical Lead Dr Raj Chandok/Dr Mohini Parmar Confidential No (items are only confidential if it is in the public interest for them to be so) The Governing Body is asked to: To note and approve the final Ealing ICE Review Recommendations and next steps for implementation. Summary of purpose and scope of report Ealing CCG is currently undertaking a major transformation change programme of work as part of the SaHF, Whole Systems Integration (WSIC) and Better Care Fund (BCF). The ICE Review has been undertaken within this wider strategic context and we have engaged with a whole range of stakeholders and all key partners, including key professionals from primary, acute and community services from EHT ICO, as part of the coredesign of the pathway. It has also become increasingly obvious the overlaps and the need to align the pathway between the co-design of Care Co-ordination as part of the WSIC and proposed new model of ICE. The review has therefore identified a model of care to be implemented by April 2015 with the work happening in two phases: Phase 1 (within existing resources, investment and workforce): For winter 2014 (in place by October 2014): Intensive rapid response services for patients in the community and in hospital, coupled with short-term stabilisation support (i.e. 12 weeks) to prevent re-emergence of need enabled through: • • • • • Full use of existing contracted capacity, particularly for patients in the community; Agreement on criteria for 2 hour and 24 hour rapid response times Clear joint agreement and medical responsibility between GP/Consultant/ICE medics if GP refers to jointly manage the acuity of all patients; and Strong communications, dialogue and sharing information and awareness of intermediate care services between clinicians in primary care, community and in hospitals focused on the needs of the patient. 7 day working – the service should be available 08:00 to 22.00, 08:00 to 22.30 in A&E Phase 2 (potential reprofiling of resources): For April 2015: A new model of care commissioned in line with Whole Systems Integrated model and the need for increased nursing and social care support including: • • • • Clear integration within wider Whole Systems Integrated work; Agreed contract with key measures of success and mechanisms for responding to over or under performance; Integration with existing services in the community where appropriate; and Clear operational alignment with Care Navigation and Care Co-ordination model of care. Quality & Safety/ Patient Engagement/ Impact on patient services: Patients have access to the full range of support to ensure they are stable and able to remain at home before moving into ‘long term’ care co-ordination and / or self-management along the whole systems pathway The Review engaged with a range of stakeholders, from primary care, secondary care and community services. The Review held two stakeholder engagement days, which included frontline staff representatives from the Rapid Response Team, Magnolia Ward, and the Short Term Rehabilitation Team from ICE. It also took into consideration patient views of the ICE Service. Financial and resource implications The Review recommends the implementation of the recommendations into two phases. Phase 1 to be implemented within current EHT ICO contract 2014/15, within existing resources, investment and workforce. Phase 2 to be considered within the context of 2015/16 commissioning intentions and planning for the WSIC care navigation and co-ordination Workstream. Equality / Human Rights / Privacy impact analysis None Risk Phase 1 not implemented in time for winter 2014 EHT ICO rejection of shared medical responsibility between ICE and GP for those patient referred by GP. EHT ICO requesting additional funding for implementation over and above current investment. Supporting documents Ealing ICE Review Report – June 2014. Governance and reporting (list committees, groups, or other bodies that have discussed the paper) Committee name Executive Management & Innovation Committee Date discussed 26/06/2014 Outcome Recommendations agreed and to present to GB. June 2014 The Intermediate Care Service Review Report Contents About this report......................................................................................................................... 4 Executive Summary ................................................................................................................... 5 1. The Intermediate Care Service Review Project ................................................................... 8 1.1. Review background ............................................................................................................................ 8 1.2. Review objectives and expected outcomes ....................................................................................... 8 1.3. Deliverables........................................................................................................................................ 8 1.4. Review approach................................................................................................................................ 9 1.5. Commissioning intentions 2014/15 ................................................................................................... 9 2. Current model of ICE .........................................................................................................10 2.1. Current service in Ealing .................................................................................................................. 10 2.2. Current referrals, activities and performance ................................................................................. 10 2.3. Patient and carer satisfaction .......................................................................................................... 10 2.4. View from provider, commissioner staff and referrers ................................................................... 10 2.5. Benchmarking best practice............................................................................................................. 12 2.6. Opportunities ................................................................................................................................... 13 3. Proposed Service...............................................................................................................15 3.1. Vision and principles ........................................................................................................................ 15 3.3. Multi-disciplinary virtual care team ................................................................................................. 17 3.3. Medical responsibility ...................................................................................................................... 17 3.4. Integration with other services ........................................................................................................ 18 3.5. Changes to the current model ......................................................................................................... 19 4. Recommendations and next steps .....................................................................................20 Annex 1: Current model of care Annex 2: Overview of savings against key performance indicators Annex 3: Referral activity: initial model of predicted activity Annex 4: Detailed analysis Patient and GP survey, commissioners and providers feedback Annex 5: Participants in co-design workshops Annex 6: Medical Responsibility Comparison Annex 7: Governance Annex 8: Implementation Timescales 2 3 About this report Ealing CCG and Ealing Council worked together with the Ealing Integrated Care organisation to undertake a review of the current provision of Intermediate Care services to patients at risk of hospital admission and those who could leave hospital with additional support in the community. This review is part of collaborative working between commissioners and providers to shape the best service for patients in Ealing who have short term intensive needs that require a rapid and comprehensive response. This report outlines the findings from the review, including the agreed new model of care, timescales for achieving this and an implementation approach retains a focus on clinical leadership and co-design between providers, commissioners and patients. Dr Alan Hakim Lead/Chair Dr Raj Chandok Clinical Lead, ICE Dr Mohini Parmar ECCG Chair Dr Shanker Vijayadeva GP Dr John Riordan Secondary Care Representative Kathryn Magson ECCG Managing Director Dr Avani Devkaran GP Registrar and Darzi Fellow Usha Prema Commissioning Development Manager Elizabeth Youard Community Services Programme Director CWHHE CCG Collaborative 4 Executive Summary ICE Service review Ealing CCG and local authority, in partnership with their partner providers, are transforming the model of provision of health and social care provision across the borough. This is grounded in a ‘whole systems’ approach to the right care, in the right place from the right team. The Intermediate Care service is crucial to this model: responding quickly to people at risk of admission into hospital and supporting those in hospital to come home is core to care closer to home. Within this context, this project was launched to review the success of a new model of intermediate care, introduced in October 2012 as part of Ealing’s Out of Hospital Strategy – and to determine the right model of provision for the future. The existing ICE service is an essential part of the Ealing array of provision, designed to provide high quality patient care for those requiring coordinated integrated rapid response services in the community and additional support to facilitate discharge from hospital. Stakeholders from across Ealing came together to consider the current delivery model, identify what works well, and agree what the future model of provision should look like, particularly given the wider service transformation underway. The current ICE service is focused on ensuring the following outcomes for patients in the community who are at risk of hospital admission and those coming out of hospital requiring additional support: Prevention of admission / reduction in length of stay Improved patient experience and satisfaction Improved carer experience Better clinical outcomes Approach to the review To understand how the service could be improved the ICE review panel collated feedback from providers, commissioners and referrers in four ways: Existing quantitative data - analysis of service data and admissions data; Provider and commissioner working sessions to establish areas for improvement within the service; Gathering GP experiences via a survey; and Benchmarking the current model against comparable services to identify improvement opportunities. Review outcomes The aim of the service is not changing. The ICE service still plays a fundamental role in the wider provision of support for patients in Ealing – and specifically needs to: provide care and support for people at home who are risk of admission to hospital in the short term within two timescales (response four hours for the most urgent and 24 hours for others) 5 facilitate the discharge of people from hospital or inpatient rehabilitation into their own homes who require some additional support for the short term for this to happen, Ensure that in both cases the ‘step-down’ in the level of support is smooth and does not put the patient at risk of requiring intensive intervention in the short term. The review therefore identified a revised model of care, with associated changes to workforce, medical responsibility and length of provision. The review proposes a service with four core features: Model of care – a service which provides immediate intensive support (in 2 hours for some patients and 24 hours for others) in a comprehensive manner, backed up by short term nursing, therapy and social care support to ensure patient is stable in the medium term. It will have a degree of fluidity in the service to enable patients to move across areas of the service depending on the intensity of the support they require; Collaborative working – the service will remain a stand-alone team that interfaces closely with the wider Care Co-ordination service, GPs and others to support ‘shared patients’ and to facilitate smooth transition from one to the other; Communications – referrals and clinician-to-clinician discussions for patients who are at risk of admission to hospital in the next few days or whom require additional support to return home from hospital; and Workforce – the right mix of nursing, social care, therapy and other staff to enable immediate intensive support for approximately seven days, and short term support for up to twelve weeks. Recommendations The review has therefore identified a model of care to be implemented by April 2015 with the work happening in two phases: Phase 1 (within existing resources, investment and workforce): For winter 2014 (in place by October 2014): Intensive rapid response services for patients in the community and in hospital, coupled with short-term stabilisation support (i.e. 12 weeks) to prevent reemergence of need enabled through: Full use of existing contracted capacity, particularly for patients in the community; Agreement on criteria for 2 hour and 24 hour rapid response times Clear joint agreement and medical responsibility between GP/Consultant/ICE medics if GP refers to jointly manage the acuity of all patients; and Strong communications, dialogue and sharing information and awareness of intermediate care services between clinicians in primary care, community and in hospitals focused on the needs of the patient. 7 day working – the service should be available 08:00 to 22.00, 08:00 to 22.30 in A&E Phase 2 (potential reprofiling of resources): For April 2015: A new model of care commissioned in line with Whole Systems Integrated model and the need for increased nursing and social care support including: Clear integration within wider Whole Systems Integrated work; Agreed contract with key measures of success and mechanisms for responding to over or under performance; Integration with existing services in the community where appropriate; and 6 Clear operational alignment with Care Navigation and Care Co-ordination model of care. Recommendations As an output of this review Ealing CCG, Ealing Local Authority and Ealing ICO will establish an Implementation Group to take this work forward and collectively deliver on the outcomes above, as an integral part of the Whole Systems Integrated Model, including links with the development of the integrated nursing model. The Implementation Group will report to the Urgent Care Board and through them to the Joint Management Team and the Health and Wellbeing Board. The work will continue to be framed by the principles that have guided the review: Collaborative development including provider, commissioner and service users; Focus on outcomes for patients – high quality care close to home with a focus on sustainability and reablement; and Being iterative and able to change to improve, particularly learning from the winter provision for the model commissioned in April 2015. 7 1. The Intermediate Care Service Review Project 1.1. Review background This document summarises the findings from a review of the Ealing Intermediate Care service and outlines areas of opportunity for collectively achieving improvements for patients in the community and in hospital. The service provided by Ealing Hospital Trust (EHT) Integrated Care Organisation (ICO) commenced in October 2012 with an investment of £4.32m. ICE is a key Quality Innovation Productivity and Prevention (QIPP) Scheme for 2013/14. Through Whole Systems Integrated Care and the Better Care Fund Ealing is implementing an new model of provision across Health and Social Care. This has created the need – and opportunity – to ensure that ICE provides a service which is in line with the future plans for provision of care for the residents of Ealing. 1.2. Review objectives and expected outcomes The objective of this review was to assess the current ICE service model and agree priority areas for improvement particularly within this context. To achieve this, the review looked at: The current service; operational delivery successes and challenges; and gaps in the service and future model of provision. The review proposes an improved, effective and efficient Intermediate Care service that works as a core part of the emerging Whole Systems integrated care in Ealing. The new service model will deliver: immediate and short term support to people at risk of admission into hospital, including those identified by GPs, social workers and other professionals in the community; nursing, social care and therapy services to stabilise patients and then ‘move them on’ to independence and / or long term support; a service that provides care for all residents from Ealing; clarity about medical responsibility and clinical delivery; agreed criteria for use of the ICE service – and discharge into self-care, care coordination services, care navigation or other forms of support; maximised and prioritised use of resources within the service; primary care confidence in responsiveness and quality Value for money. 1.3. Deliverables The key deliverables for this review1 are: 1 Whole systems pathway ‘As Is’ and ‘To Be’ process map; Benchmarking examples of best practice ICE Service Annual Review Scope v6 Item 2 8 Short, medium and long-term recommendations for achieving the new model 1.4. Review approach The review has been undertaken for Ealing Clinical Commissioning Group (ECCG) as the commissioners of the service, supported by PPL Consulting. The approach has been purposefully collaborative and included numerous joint sessions between commissioners and providers. Both qualitative and quantitative methods of measurement were used to establish the gap between the intended and actual performance of the service and to develop the new model of care. Data collection methods are: Existing quantitative data - analysis of service data and admissions data; Provider and commissioner working sessions to establish areas for improvement within the service; Gathering GP experiences via a survey; and Benchmarking the current model against comparable services to identify improvement opportunities. 1.5. Commissioning intentions 2014/15 The commissioning intentions set out how the ICE service will fit within the wider Ealing model of care. There is a clear ambition to scale up the service and in particular to deliver high quality immediate and short term support to people in the community at risk of admission to hospital. Detailed investment decisions await the outcome of this review and the development of the revised specification. The scale-up of this service will depend on a number of factors; the aim is to develop it collaboratively with Ealing ICO in both phase 1 (winter 2014) and phase 2 (April 2015). 9 2. Current model of ICE 2.1. Current service in Ealing ICE is an integrated service across health and social care. It encompasses a number of services including: Single Point of Access (SPA), Rapid Assessment, Rapid Response, Rehabilitation, Reablement and Step-up bedded service supporting both medical and physical needs (Annex 1). The service places the patient at the center of the coordinated model of care, improving patient and carer experience. By providing high quality clinical care to patients at home the number of urgent hospital attendances and the length of hospital stay will be reduced. 2.2. Current referrals, activities and performance Referrals and activity October 2012 – March 2014 A comparison of the current level of ICE performance in relation to the initial modeling and target set for the service indicates a low level of activity (see Annex 2 and 3). 2.3. Patient and carer satisfaction A Trust wide ICE Patient Experience survey was conducted between September and November 2013. A total of 100 questionnaires were reviewed for the Rapid Response (RR) and Supported Discharge (SD) team. Generally the response to questions was very positive (over 80%). (Annex 4). Patients rated the care they received very highly: RR 98% Excellent or Very Good SD 94% Excellent or Very Good Areas for improvement were: Patients having contact details for the service (RR satisfaction 69%) Patients being informed of changes to appointments (RR satisfaction 67%) 2.4. View from provider, commissioner staff and referrers Two working sessions and a GP survey (Annex 4) were conducted to identify the key areas for improvement within the service. Approximately 30 participants attended the sessions including representation from health and social care commissioners and providers (Annex 5). 12% (38 out of 327) of the GPs in Ealing responded to the survey providing coverage across the 7 localities. We identified what has worked well: • • • • Service users experiencing better quality targeted care Effective working relationship between ICE and A&E Effective communication channels between ICE and Reablement services Improved discharge pathways Our stakeholders identified internal areas for development that could address underlying issues for the operational delivery of intermediate care services. We also identified five areas for improvement: 10 overall model of care - patient journey from access to discharge; collaborative working; communications including information and data sharing; staffing recruitment and retention; and Skills, roles and responsibilities. 7 day working a) Model of Care The participants determined that the current model does not meet the needs of different patients with diverse needs. Specific areas for improvement included the need to: broaden access for Ealing patients from hospitals beyond that of EHT; broaden existing referral pathways including but not limited to Imperial, North West London Hospitals Trust and Hillingdon A&E; improve the Rapid Response service available across the borough through work alongside primary care services; and Improve clarity regarding the patient cohort deemed appropriate for the service. b) Collaborative working Participants identified a need to develop stronger links between services and sought improved integration with external organisations. They highlighted disparity between GP practices in the level of engagement with the service, resulting in: a variable number of referrals; and A lack of clarity regarding the role of social services and community pharmacists in delivery. c) Communications The feedback received indicated a lack of awareness across Ealing GPs regarding the function of the service. Ineffective marketing was identified as a contributing factor in the resultant low utilisation of the service. The majority of GPs perceived that – when used – the referral process to be easy or satisfactory with the main barrier identified as information duplication. In particular the need was identified for an effective information system, replacing fax and emails, to share the referral form. d) Staffing recruitment and retention Participants in the survey and workshops indicated that the service requires workforce development – primarily around numbers – to meet the requirements for 7 day working. Recruiting and retaining staff remains a challenge for the service due to the complexity of the responsibilities and roles outlined within the multi-disciplinary working model. The feedback also identified a need for training support. The review identifies a greater diversity of roles within the multi-disciplinary team as being a potential area for future improvement within the service. e) Skills, roles and responsibilities The feedback identified the need for clear clinical leadership, consistent multi-disciplinary assessment of need between the referrer and the ICE staff, and the need for a more efficient handover process back to the referring GP at the time of discharge. 11 2.5. Benchmarking best practice This section sets out a comparison of Ealing’s current model with some of the similar services offered in other boroughs. Table 1 provides an outline of our current service model against comparable services to identify opportunities for improved design. Key comparative service examples include: STARRS – Brent and Harrow ICRS - Hounslow Integrated Primary Care, Rapid Response Service – Camden (For detailed information see Annex 4.) Table1. Intermediate care services comparison Themes Ealing Hounslow (Intermediate Care (Integrated Ealing) Community Response Service-) a) Model of Care Referrals accepted from GP, A&E departments, Urgent Care Centers. Service responds to patients in non-acute bedded units. Mon - Fri 8am-8pm and reduced service over the weekend. Referrals accepted from Urgent Care, Emergency Department & Acute Assessment Centre, Acute hospitals, Rehabilitation facilities, GP, Community health practitioner, LAS, Social Care practitioner. Service responds to patients at Charing Cross, Ashford, St Peters and Ealing Hospital. Camden (Integrated Primary Care, Rapid Response Service) Harrow & Brent (STARRS) Referrals accepted from a range of providers. Referrals accepted from clinicians or social care professionals. Service responds to patients in non-private hospitals within the Greater London area. Mon – Fri 8am8pm. Sat – Sun 9am-3pm. Mon - Fri 9am-5pm. Service available to Camden residents living at home requiring immediate intervention. 7 days per week 7am7pm. Service available to all service users (18+) registered with a Hounslow GP. b) Collaborative working c) Communications Integrated operating methods so that the patient experience is that of a single service. The provider is responsible for raising awareness of the Integrated operating methods so that the patient experience is that of a single service. The provider is responsible for raising awareness 12 Themes Ealing (Intermediate Care Ealing) Hounslow (Integrated Community Response Service-) Camden (Integrated Primary Care, Rapid Response Service) service and managing issues which impact on referrals. e) Skills, roles and responsibilities Rapid Response assumes medical responsibility for patients for as long as they are in the service. Medical responsibility transfers to the patients GP upon referral to short term services. Clinically led MDT. Medical responsibility shared with GP. Harrow & Brent (STARRS) of the service and managing issues which impact on referrals. Medical responsibility remains with the GP where STARRS deliver services within a community setting. Medical responsibility within the rapid assessment and response unit lies with the Intermediate Care lead clinician. Accountable senior clinical leadership. *For further detail see Benchmarking Intermediate Care document. 2.6. Opportunities We drew together a wide range of insights from all the research and distilled these insights into five opportunity areas. These areas are intended to provide a platform for the service design from which to generate ambitious new ideas, combining the aspirations of the service with the strategic priorities in Ealing. Table 2. Opportunity areas Area What could be improved a) Model of Care How could we improve a) Develop the existing service to respond better to patient need. b) SPA process c) The service to be equitable to all Ealing residents. d) The service to differentiate between users based on urgency of need. e) Increased referral rates from health and social care professionals. f) Immediate care followed by short 13 Develop a single assessment process with clear access pathways. A response appropriate to the urgency of need. Streamline SPA processes. Widen the referral routes into the ICE service. Proactive case identification either into or out of hospital. Put in place provision for 7-day intensive support followed by up to 12 weeks of ‘step down’ support prior to discharge / moving on A greater role for social workers, reablement staff and community pharmacists in multi-disciplinary Area What could be improved How could we improve term provision to ensure stability before discharge or handover b) Collaborative working c) Communications d) Staffing recruitment and retention e) Staff skills and roles working. a) Alignment of ICE with wider services (e.g. WSIC). b) Work with other services based in A&E’s adjacent to Ealing. a) Communication channels between ICE and the community services. b) Clarity of purpose and role for GPs c) Data sharing within the MDT. d) Data sharing between the service and referrer. e) Awareness of the service amongst all providers to increase appropriate referrals for all patients across the borough. a) Extended hours of service delivery. b) Mix of skills including high quality nursing, social care and therapy services c) Recruitment for the ICE team. d) Involvement of social care. a) Further consideration to how medical responsibility is shared by the GP and the ICE service. b) Flexible working practices including across teams. Develop contractual commitments that govern ICE as an enabler for integrated working. Explore the connection between LAS and ICE. Develop the data sharing infrastructure to support the service. Advertise the role of the service across health and social care settings within the borough, particularly in primary care Design a flexible sufficiently resourced staffing model to cover the 7 day working service that provides immediate and short term resource Introduce team based social workers. Greater engagement of the voluntary sector. Explore opportunities to ‘share’ resources with emerging care navigation and care co-ordination teams Agree roles and responsibilities for different team members. Agree medical responsibility and clinical provision Ability to work flexibly, off site and in people’s homes. Regular training and education to up-skill and multiskill staff. Not all of these changes are possible or appropriate for Ealing but many of them inform the new service model proposed below. 14 3. Proposed Service 3.1. Vision and principles Our future service will support people to receive care at home whenever possible by ‘providing an effective and efficient whole system integrated Intermediate Care Service wrapped around primary care.’ Based on the opportunities identified in section 2 and through consultation with colleagues across the system, principles have emerged that will guide the future design and development of the service. Stakeholders agreed on the following principles for the future service: Focused on supporting people to remain at home safely and comfortably – and / or to come home quickly and safely Flexible and responsive to patients’ evolving needs; Provision (including referrals and planning) done by a multi-disciplinary team; Responds to the patient within appropriate timescales according to the patients need; Access to specialist support as needed; Seven day working; An effective supported discharge system from the service; Smooth connections between different services (e.g. WSIC, OPRAC etc.); Alignment of services to GP networks; and As close to single integrated patient records as possible. The key aims of the service remain: Provide responsive high quality support for clinical, social and functional needs to prevent hospital attendances and admissions; Reduce unnecessary length of stay in hospital; Provide immediate and short term support to enable patients to be stable and confident at home (whether moving on to ‘self-care’ or to a long-term package of support) with some of this support being provided within 2 hours and other patients receiving support within 24 hours; and Deliver integrated coordinated care that is patient centered, coordinated and offers continuity of care to high need patients. Figure 1 overleaf illustrates the agreed ICE model of care. 15 Figure 1 Agreed ICE delivery model The new service has six core features: 1. Rapid response (2 hours for some and 24 hours for others) for patients who are at risk of hospital admission in the immediate or short term without the provision of additional nursing, social care or therapy support 2. Support for patients who are able to be discharged from hospital with similar additional support 3. Services need to be responsive to provide both rapid comprehensive high end support immediately and comprehensive nursing, therapy and social care support for a short period, adding capacity in effect to the services that primary care, community health and social care are already offering; 4. As patients are likely to move between the ‘differing intensities’ of support there should be a fluid way to do this i.e. a ‘virtual care’ team providing both immediate and short term care; 5. The ICE service remains a stand-alone team from the wider Care Co-ordination service but interfaces closely around shared patients; and 6. Immediate intensive support is for approximately seven days and ‘short term’ support for up to twelve weeks (as in figure 1 above) 16 3.2. Multi-disciplinary virtual care team The service is delivered by an ‘ICE Care Team’ with a skills mix including health, social care, therapy, medicines etc. The service will have access to specialist professionals to assist where required. Figure 2 demonstrates the core services with rapid access to specialist services. Figure 2. ICE team This team is similar to the emerging multi-disciplinary team at the heart of the Ealing Whole Systems model. It will sit alongside this more long term team. Work is underway to define exactly how the two services will interact and intersect, including options around sharing resources and expertise. 3.3. Medical responsibility Joint medical responsibility for patients who are in the ICE service is critical. The approach is to have a clear joint agreement and medical responsibility between GP/Consultant/ICE medical team to jointly manage the acuity of all patients. The approaches are: Patients referred from the community: for patients who are referred from the community their registered GP the approach is to have a clear joint agreement and medical responsibility between GP/consultant. This is a change to the current model of care. Patients referred from hospital: for patients who are referred from hospital, either from A&E or being discharged from an inpatient bed, the ICE team will have Medical Responsibility. This will transfer back to the GP once the patient is ‘discharged’ from the 17 ICE team, whether they are discharged into self-management or into a long term package of care. This is no change from the current model of care. Annex 6 compares current and future Ealing Medical Responsibility to other models of care. 3.4. Integration with other services ICE is a core part of the emerging Whole Systems model of care in Ealing where patients receive appropriate levels of care co-ordination and care navigation according to their needs. Figure 3 shows this emerging model. There is still discussion around the boundary between the 12 week provisions critical to the ICE model (see red box figure 3). There are also activities underway to agree which existing services may form part of this 12 week provision. In summary the Whole Systems work and the ICE work are coming together around a number of outstanding questions: 1) What is the boundary between ICE and wider care co-ordination particularly at the high end of care co-ordination? 2) What existing services may be incorporated into the ‘short term’ aspect of ICE / high end aspect of care co-ordination? These are being addressed in the short / medium term as part of the wider BCF activities being overseen by the Urgent Care board and the Joint Management Team. Figure 3 ICE in the wider context Need / Risk of admission ICE Up to 7 days Integrated Care / MDT Up to 12 weeks Care co-ordination Intensive support MDT support Care navigation Self management Identification and support for dementia and Falls runs throughout Population (illustrative) 18 3.5. Changes to the current model The proposed new approach to Intermediate services in Ealing requires a number of fundamental changes to the current model. The population being served (339,000) – and the types of services – will expand particularly within the ‘short-term’ support that follows immediate response. Table 3 highlights the key changes to the current model and how this will be different for patients. Table 3. Key changes to the current model What has changed Services included in ICE Access How is it different for patients Short term support package is likely to require respecification and redesign of some existing services currently outside of the ICE service (e.g. District Nursing, Rehabilitation and Reablement) More flexibility in the criteria for accessing the service Patients have access to the full range of support to ensure they are stable and able to remain at home before moving into ‘long term’ care co-ordination and / or self-management Responsiveness of the ICE model to the needs of patients in the community A service that operates within 2 hours for some patients and 24 hours for others A service that operates 7 days/week. Care planning will involve Social Services and Community Pharmacists. Single assessment undertaken in their ‘home’ environment. Home visits from health and social care professionals. Increased access to the service through an enhanced referral ability amongst professionals. A consistent referral route into the system. Access to a direct patient advice line. Referral Broaden referral pathways engaging with hospitals outside of the borough Cohort Multi-disciplinary approach to determining the suitability of referrals with feedback given to the referrer Clear joint medical responsibility Differing levels of provision within the service to meet patient need. Access to the service based upon registration with a GP in Ealing. For GP referrals there is a clear agreement joint medical responsibility GP/consultant ICE Team to manage the acuity of patients. Professional responsibility is shared by health and social care A clear Single Assessment Process enabling the patient to tell their story once. A seamless experience of care provision across the service (contractual agreements). Improved access to and visibility of social workers. Responsibility 19 4. Recommendations and next steps The ICE review sets out the outcomes that commissioners want to see by April 2015. The detailed steps to achieving this will be co-designed and agreed by the implementation group detailed below. The recommendations and the outcome and delivery of the short term improvements will also inform Ealing CCG’s commissioning intentions for 2015/16 and beyond. The vision is set within the context of Whole Systems Integrated Care (WSIC) and support. The review acknowledges the improvements required in the current model of delivery to achieve the long term vision will be in phases, as it will be part of a journey to establish the full model of care. Delivery is against two phases as set out below. A) Phase 1: Immediate and short term response in place for Winter 2014 Recommendation Put in place immediate and short term response to patients in the community and being discharged from hospital ensuring full utilisation of current resources and ‘top-up’ of provision where necessary and possible Ensure full use of existing contracted capacity, particularly for patients in the community. Implement response timescales of four hours for some patients and 24 hours for others Ensure that GPs, consultants, ICE and others agree on joint medical responsibility from referral to discharge Set up and facilitate mechanisms for opening referrals from other professionals in the Community. Put in place multi-disciplinary team including enhanced nursing, social care and therapy resource to ensure support to people in the community and safe supported discharge. Greater awareness of the ICE service by all potential referrals to increase use of capacity. 7 day working: 08:00 to 22.00 and In A&E 08:00 to 22:30 B) Phase 2: New contract in place for April 2015 Recommendation 1. Put in place detailed delivery model (e.g. wider existing community and social care services to be included in the model, particularly the provision of services post immediate response) 2. Take forward necessary procurement and contracting requirements, including procurement and contracting options Implementation and Governance It is proposed that the Ealing Urgent Care Board will be responsible for the delivery of the recommendations under the Urgent Care Programme of Work, reporting to the Health and Social Care Joint Management Team, Ealing CCG Executive and to the Health and Well Being Board as part of the integration agenda under the Better Care Fund and the WSIC Programme of work. The key priority for the Ealing Urgent Care Board will be winter planning for 2014/15, ensuring the improvements recommended in Phase 1 are delivered and in place for winter. An Implementation Steering Group will be established to agree an action plan on the details of the delivery to the timescales for of Phase 1 and Phase 2 of the recommendations. The Group will utilize current governance mechanisms of the Better Care Fund and Urgent Care Board for 20 reporting and accountability for delivery (see Annex 6). The timescales for delivery of the recommendations are outlined with key milestones in Annex 7. The overall aims and objectives of the steering group will be to work within the following principles: Agree and put in place building blocks to implement phase 1 and 2 of ICE changes within the WSIC Continue to co-produce with providers and patients Ensuring clinical oversight and governance to support rapid implementation Proposed membership of the Implementation Group ECCG Clinical Lead(CRO) – Chair ECCG Chair CCG Senior Management Lead(SRO) Consultant Physician and Geriatrician Darzi Fellow/GP Registrar Key frontline staff from ICE Team: Rapid Response Service, Magnolia Ward, Short Term Rehabilitation Social Services Reablement Team and Care Management Executive Director HR and Operations, EHT ICO EHT ICO Director of Community Services(Ealing) Network Provider Leads A&E Representative Representatives from key community services, such as falls, district nursing. 21 ANNEX 1 - Current model of care GP management, community services (too well for intermediate care) RAPID RESPONSE RAPID ASSESSMENT At risk of hospital admission SPA Access / signposting Normal place of residence / A&E treatment and triage SHORT-TERM SERVICES Step-up bed Intensive intervention ALoS 7-10 days Rehab bed Up to 6 weeks rehabilitation Normal place of residence Up to 72hrs intensive intervention Normal place of residence Up to 6 weeks rehabilitation Acute hospital admission (too ill for intermediate care) 22 Combined health and social services ANNEX 2 – Overview of savings against key performance indicators Table1. Key performance indicators Key performance indicators Reduction of acute non-elective adult admissions for patients registered with an Ealing GP per annum (from 2011/12 baseline)* 2012/13 3,600 2013/14 3,800 2014/15 3,900 Reduction in A&E/UCC attendances for adult patients registered with an Ealing GP against 2011/12 baseline* 875 875 875 * The 2011/12 baseline will be calculated as the out-turn activity for the period 1st July 2011 to 31st March 2012, extrapolated to 12 months, as reported by the ACV. (Source: ICE Future Discussion Paper). The ECCG and Ealing Hospital Trust (EHT) 50/50 risk sharing agreement identifies that, subject to actual performance against KPIs (outlined below) either ECCG or EHT will be required to reimburse other party for over or underperformance respectively.` 1. Intermediate Carethe Service 1. Intermediate Care Service YTD 200 1,000 100 500 0 (100) April May June July August September October November December January February March 0 (200) (500) (300) Non-elective adult admissions - Change 2012/2013-2013/2014 Month / Year Non-elective adult admissions -2013/2014 Non-elective adult admissions - 2012/2013 Non-elective adult admissions - Change 2012/2013-2013/2014 April 2,440 2,479 (39) May 2,346 2,625 (279) June 2,330 2,533 (203) July 2,470 2,490 (20) August September October November December January February March YTD Annual 2,395 2,403 2,411 2,418 2,368 2,394 2,191 2,341 28,507 28,507 2,458 2,314 2,425 2,359 2,414 2,487 2,246 2,512 29,342 29,342 (63) 89 (14) 59 (46) (93) (55) (171) (835) (835) Non Elective Adult Admissions – ICE change from 2012/13 - 2013/14 23 (1,000) ANNEX 3 – Referral activity: initial model of predicted activity GP management, community services (too well for intermediate care) Inappropriate: 688 Activity: 7,570 RAPID ASSESSMENT incl. 808 RR to STS transfers At risk of hospital admission SPA Access / signposting Other intermediate care services: 1,528 Normal place of residence / A&E treatment and triage Activity: 4,546 ACS: 1,950 Tier 2: 1,667 Existing: 929 Activity: 977 ACS: 390 RAPID RESPONSE Tier 2: 167 Existing: 420 Step-up bed Intensive intervention ALoS 7-10 days SHORT-TERM SERVICES Rehab bed Up to 6 weeks rehabilitation Normal place of residence Up to 72hrs intensive intervention Normal place of residence Up to 6 weeks rehabilitation Combined health and social services Activity: 808 ACS: 546 Tier 2: 150 Existing: 112 Activity: 3,569 ACS: 1,560 Tier 2: 1,501 Existing: 509 Acute hospital admission (too ill for intermediate care) COSTS SPA & RA cost: £114k Total cost: £3,929 Existing Cost: £1,406k Add Inv: £2,523 RR non-bed cost: £1,605k Non-bed cost: £2,310 Existing: £171k New: £2,139k Step up beds cost: £1,619k Existing: £1,235k New: £384k STS cost: £592k Current referral activity Referrals to SPA A&E referrals GP referrals Other source Appropriate Inappropriate Initial activity model Activity 2012/13 7,570 15,568 894 (56%) 527(34%) 171 (10%) 1,592 13,976 Activity (extrapolated) 2013/14 No longer reported 1,336 (61%) 721 (33%) 130 (6%) 2,187 No longer reported Days 8.78 2.12 28.12 Days 9.62 2.45 33.53 5,354 688 AVG LoS Magnolia Rapid Response Short Term Rehab 24 ANNEX 4 – Detailed analysis Patient and GP survey, commissioners and providers feedback ICE Service Review Detailed Analysis 25 ANNEX 5 - Participants in co-design workshops Name Dr Alan Hakim – Lead ICE Review/Chair of Ealing Urgent Care Board Dr John Riordan - Secondary care Representative Kathryn Magson – Managing Director Dr Mohini Parmar – Chair of Ealing CCG/GP Dr Raj Chandok – Vice Chair of Ealing/Clinical Lead Dr Avani Devkaran – Darzi Fellow/GP Registrar Dr Shanker Vijayadeva – GP Usha Prema – Commissioning Development Mgr. Nicola Bradley – Head of Continuing Care, ECCG Clare Laffey – Care Co-coordinator, ECCG EHT ICO Paul Stanton – Director of HR, EHT ICO Jo Paul – Community Services Director Bill Lynn – Deputy Chief Executive, EHT ICO Fiona Wisniacki – Lead EHT Emergency Dept. Consultant Kisha Moore (ED) Pat Rubin- Interim Head of Operations Prakash Pote (ED Physiotherapist) Dinusha Arya (Physiotherapist) Bev Mitchell- Head of Therapies Jill McCartney - Service Lead for Claypond’s Hospital and ICE Angela Brooke – Head of Adult Services Penelope Johnson - I.C.E Service Manager, Short Term Rehab Team Lead Linda Narzako - Consultant Nurse Admission Avoidance Unit and Service Lead IV therapy Dr David Slovick Johnny Swartz - Consultant Physician and Geriatrician Clinical Lead - Department of Medicine for Older People Patrick Laffey ICE GPs RRT SRT Sylvie Wood Bhupender Sethi (Falls Service Mgr.) Ealing Social Care Stephen Day Gail Oliver Anne MacAdam plus 2 team leaders Other: Elizabeth Youard 26 ANNEX 6 – Medical Responsibility comparison Note: Camden is not specified Ealing (current) Ealing (proposed) Hounslow Harrow & Brent GP responsibility Joint GP/ICE Consultant responsibility GP responsibility GP responsibility The ICRS will accept referrals from GPs Doctors with current responsibilities of care for the patient. GPs accept medical responsibility for STARR’s patients, and will provide direct contact information for use by exception. Medical responsibility will transfer to the patient’s GP on referral to short term rehabilitation services or on discharge back to generic community services / primary care (i.e. any period following the rapid response elements of the pathway). For those patients who are referred from the community their registered GP joint medical responsibility. At the same time the ICE team will provide the clinical input required. This is a change to the current model of care. On receipt of referral the Integrated Community Response Team will have a telephone conversation with the patients registered GP to agree medical responsibility for the patient whilst under the team’s care. Medical responsibility within all STARRS services where care is delivered in a community setting remains with the patient’s GP, with the exception of: Team responsibility Team responsibility Team responsibility Team responsibility The Rapid Response component (Intermediate Care lead clinician) will assume clinical/medical responsibility for the patient from the point of acceptance of the referral to the SPA for For those patients who are referred from hospital, either from A&E or being discharged from an inpatient bed, the ICE team will have Medical Responsibility. This will transfer back to the GP The ICRS will accept referrals from GPs Doctors with current responsibilities of care for the patient. NA On receipt of referral the Integrated Community Ealing (current) Ealing (proposed) Hounslow a Rapid Assessment, and for the duration that the patient is within this service. Robust protocols and mechanisms will need to be set up and agreed with Ealing GPs to ensure effective handovers and excellent communication. once the patient is ‘discharged’ from the ICE team, whether they are discharged into selfmanagement or into a long term package of care. This is no change from the current model of care. Response Team will have a telephone conversation with the patients registered GP to agree medical responsibility for the patient whilst under the teams care. Consultant responsibility Consultant responsibility Consultant responsibility Consultant responsibility Acute consultants will be medically responsible for Early Supported Discharge Patients within the Discharge Support function. NA Acute consultants will be medically responsible for Early Supported Discharge Patients within the Discharge Support function. Handover of care on discharge will be in writing via discharge summary and onward referrals as appropriate. 1) The Consultant Community Geriatricians are responsible for step up admissions via A&E or where they have assessed the patient immediately prior to admission. 28 Harrow & Brent 2) The Early Supported Discharge element of the Discharge Support service, where cover is provided through the discharging inpatient team (acute consultant adopts MR). ANNEX 7 – Governance Health and Wellbeing Board JSNA, H&WB Strategy, Integration, ITF Statutory Accountabilities Governance and Oversight of Integration Health Watch NHS Providers Ealing Whole Systems Integration Board Oversight of Project Delivery Integration WorkStreams Ealing Council NHS Ealing CCG Governing Body Health & Social Care Joint Management Team Programme Management Project/Task Groups Finance and Governance Working Group Commissioning Development ICE Implementat ion Group, Dementia Board, Elderly/falls Grp Urgent Care Board H&SC Integration Model of Care Steering Group Primary Care Development GP network Development groups Annex 8 – Implementation Timescales Jun-14 Jul-14 DRAFT ICE Implementation Milestones Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 2015/16 Operating Model Phase 1 - planning Phase 2 - planning Medical Responsibility, up to 12 week support, Supported Discharge, Enhanced Nursing (virtual ward), Interfaces between services Go Live Communications Governance WSIC Model Phase 1 Go Live Phase 2 Go Live Communications and Engagement with key stakeholders: Primary Care, Secondary Care, LAS, Social Services, voluntary sector Patient/carers Ealing Exec Ealing GB ICE Implementation Steering Group . Reporting to Monthly Ealing Urgent Care Board Report Ealing Exec via Urgent Care PID via Ealing Urgent Care Board Integrate with Ealing CCG broader Strategic Developments WSIC WISC Contracting Process Outline Plan Pilot for Care Co-ordination & Navigation submission Implementation Phase - shared Management Team in place Full Business Plan Phase 1 - In yr variation 2014/15 agreed Phase 2(2015/16): Commissioning Intentions/Contract Round Performance Phase 1: Performance - monthly monitoring 30
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