Transcript Evercare Celebrating Success

Critical Interfaces within the Project
Luton NHS tPCT
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What we’ve achieved in Luton
•The team
•Caseloads
•Training and education
•Funding from WDC
•Links & modernisation
•Patient database in place
•Retrieval of data
What we know about our patients?
3% of >65’s make up 47% of total emergency admits
Key challenges faced in Luton
•Pace
•Funding
•Data capture
•Building key relationships
•Limited resources
Key intervention – GP Practices
Practice
Nurse
Practice
staff
GP’s
Advanced
Primary
Nurse
Receptionists
District
Nurse
Practice
Manager
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What we did….
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Ups and Downs
•How they reacted
•How we felt
Process
(The Sell)
•Collaborative meetings
•1-2-1 meetings
•Lead Nurse involvement
•Feedback
•Action Learning
•Celebrating Success Conference
•Gave it some time
How are we getting on
• Joint visits
• The system works!!!!
• referrals to APN from GP
• referrals to DN from APN
• messages being passed on
• Smiles
• Invite to xmas party!!!
Other Key Primary Care Interfaces
Social services
• Home care on prescription
• training
Out of hours
• Patient identification
• Communications
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Treatment
Centre
Primary Care
Contractors
Walk in Centre
Evercare
Learning &
Research
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The Future of the Workforce
Evercare
Model
•P2
•Autonomy
•Patient Choice
•Nurse Led Services
Walk
In
Centre
•Training & Development
Luton
Treatment
Centre
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1:1 and with carers/families
Case management: anticipatory care
Primary and secondary care
Short/long term
Chronic disease
Prevention & management of chronic conditions
Term approach
Evercare
Long-term case management
Treatment Centre
Nurse-led
Multi-disciplinary assessment
Mainly booked appointments
Self-referral and primary & secondary care
3 Dimensional
Integration
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GP
APN/P
PN/P
“High
Level
Practice”
Trained,
Skilled Staff
Cadet
Scheme
Skills Escalator
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What we learned
•Role definition & clarity
•How people react to change
•Don’t avoid difficult situations
•Don’t underestimate how difficult this is for
all involved
•It takes time – well 8 months!!!
•Humour can be powerful