Transcript Introducing Sophie - Home

We need to talk about
Sophie
Sarah Clegg
Dona Milne
Background
• Getting it right for Every Child
• NHSL Strategy for Children and Young
People 2013-2020
• “Life stages” approach
• Understanding the health needs of
children and young people in Lothian
Background
• NHSL Strategic Planning
• Patient Pathways
• Hannah, Scott, Callum, Sophie
• Patient pathway
approach:
– “will inform large
and significant
parts of the final
plan”
– “seen as major
focus for staff,
patient carer and
third sector
involvement”
Urgent local service planning and redesign continues across acute and primary care
1. Use our intelligence and
evidence to agree about five
fictional patients with varying
degrees of care needs who
illustrate key patient pathways.
Callum
38, depression,
alcohol, drugs
2. Map the care needs of these
patients and how we currently
meet them. Include both planned
and unplanned care.
Agree principles we are
working to.
Callum’s care pathway now
3. Get everyone together
(patients, clinicians) to agree how
we can meet these needs in a
radically different way, taking
into account agreed principles.
4. Use our data to plan
how we deliver these
pathways as services.
Callum’s new care pathway
Hannah’s care pathway now
(LTCs, multiple morbidity)
Scott
75, confusion, ↑BP,
arthritis, diabetes
Scott’s care pathway now
Hannah’s new care pathway
Workforce
Finance
Facilities
IT etc…
Hannah
60, diabetes,
↑BP, COPD
PRINCIPLES e.g. workforce
6 dimensions of quality
integration of H&SC etc…
(younger, frequent use of emergency/urgent care)
Scott’s new care pathway
(frail, elderly)
Sophie
3, epilepsy
Sophie’s care pathway now
Sophie’s new care pathway
March
2014
April
2015
Hannah – overview of approach
The House of Care
• Co-ordinated service delivery model
• Oct 2013 report from The Kings Fund
• All individuals with long term conditions
not just “high risk”
• Active role for patients – personalised care
planning
• Health professionals move from “primary
decision maker” to partnership model
The House of Care
• Link between care planning for individuals
and commissioning for local populations
• Best use of local authority services,
community services and more traditional
health services
• Focus on reducing health inequalities, on
prevention, anticipation and supported
self-management
• Person at the centre of all decisions
The House of Care
Sophie’s team
• Clinical Team: Sarah Clegg, Lesley Ross,
Edward Doyle
• Public Health: Dona Milne
• Strategic Planning: Mike Massaro-Mallinson,
Fraser McJannett
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Public Involvement: awaited
Modernisation Team: awaited
Social care: awaited
Data visualisation: Becky Kaye
GP record
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Meds from 3 BNF chapters
9 med requests in last 12 months
3 courses steroids in last 12 months
Letters from practice requesting asthma review
Practice nurse 1 attended, 1 DNA
6 gp appts in last 12 months
1 gp DNA
1 dermatol referral – DNA
1 RHSC ARU admission– acute wheeze
1 referral CAMHS - ?ADHD
1 call NHS24 – chicken pox contact query
TRAK record
• 3 medical paediatric clinic appts – none
attended
• 1 community child health referral for
behavioural difficulties - CAMHS
• 2 IRD in last 2 years – exposure to
domestic violence, concerns re level of
care
• 1 phone consultation with dieticians re
weight gain/healthy diet
Sophie’s story
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Feels real to me
What are the challenges
What about school?
Elephants in the room
Quality ambitions
• Person centred
• Safe
• Effective
• How do we make sense of it?
• Where do we want to get to?
• Principles
Next steps
• Engage education and social care
colleagues
• Engage out with Edinburgh – already met
with Midlothian and West Lothian
colleagues
• Voluntary sector engagement
• Patient representatives
• Planned event Spring 2015
?
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What do you think?
Is it a reasonable approach?
Do you recognize Sophie?
What have we missed?
Who should we involve and what do we
need to do next?
• Where will we end up? What will we
change?
Thank you
[email protected]
01315360471
07872417569