Transcript Relay race
Southall Initiative for Integrated Care Stakeholder Workshop 18th November 2010 Neighbourly Care, Southall Aims 1. Identify lessons from 2010 projects 2. Generate consensus about 2011 projects 3. Suggest how the Southall model could help GP Commissioning Annual Learning Cycle November Endings and Beginnings 1 Identify new priorities 4 Feedback conclusions February Training July Agree Coordinated Actions 3 Agree pilot changes & improvement measures April Review Rapid Appraisals 2 Shape new Projects 5 Showcase completed projects Southall Initiative for Integrated Care Debate Priorities. Stakeholder Workshop Date Venue Tasks Wed 25th Nov 2009 Milan Palace, Southall Listen to perspectives. Identify priority issues Dec – Feb. Form Core, Project and Oversight Teams. Secure all formal approvals including access to databases. Test extraction of data. Form team to redesign website. Prepare leadership course (course materials, accreditation, mentors). E-Star Training Date Venue Tasks Wed 10th Feb 2010 Dominion Centre Respond to learning needs expressed. Pilot questionnaires Feb-Apr. Rapid Appraisals, system models & baseline data. In-practice learning. REC Approval. Recruit into leadership course. Agree mechanisms to connect with Integrated Care Organisation, Health Communities and Polysystems. Shape system-wide changes. Stakeholder Workshop Date Venue Tasks Thurs 22nd Apr 2010 Neighbourly Care, Featherstone Rd Review information and progress. What now needs to be known? Apr-Jul. Find required information. Set up database searches. Test website. Residential teambuilding workshop. Start leadership course. In-practice learning. Agree pilot system-wide changes. Stakeholder Workshop Date Venue Tasks Thurs 8th Jul 2010 Neighbourly Care, Featherstone Rd Agree pilot changes in each theme and improvement measures. Jul – Nov. Pilot changes. Ongoing Improvement Measures. Monthly action learning sets. Local focus groups and in-practice support for learning and data-gathering. Southall Initiative for Integrated Care Conclusions. Stakeholder Workshop Date Venue Tasks Thurs 18th Nov 2010 Neighbourly Care, Featherstone Rd Feedback conclusions. Identify new priorities Nov – Feb. Gather data. Compare outcomes with other places. New project teams lead new priorities, learning from previous year teams. E-Star Training Date Venue Tasks Jan – March 2011 Various Training in the new systems and use of web resources. Feb – Apr. Write training manual about how to use this approach in other PCTs. Put information on website. Showcase the projects. Shape new projects. Stakeholder Workshop Date Venue Tasks Thurs 7th Apr 2011 TBC Critique Handbook. Export to other places. Apr – Jul. Papers for publication. Present at Conferences. Complete leadership course. Close down this cycle of inquiry and action, as the next cycle gathers pace. Southall Initiative for Integrated Care - Professional engagement by type Professional engagement by type Number of attendees 70 60 50 40 30 20 10 0 25-Nov-09 Identify Priorities: First stakeholder w orkshop 10-Feb-10 22-Apr-10 28-30 April-10 08-Jul-10 Southall Collaborative Shaping SystemTow ards Local Agreeing the Pilot Learning Workshop: w ide Changes: Health Communities: Projects for 2010 and E-star Training Second stakeholder Residential w orkshop Priorities for 2011: Event title Academic & Applied Research Unit Commissioning Community Services General Practice IT & Education Local Government Mental Health Intermediate Care Public Health Senior Management Specialist Services Patient & Voluntary Groups Relay race Boundary spanning Community Learning Southall Initiative for Integrated Care Nov 2009-2010 Diabetes Neha Unadkat Jayshree Patel Harpal Rai National Situation Diabetes UK Statistics: – 2.8 million people have diabetes in the UK (2009) – 16% have undiagnosed diabetes (0.5 million people) – By 2025 > 4 million people will have diabetes Risk: – South Asian, African, African-Caribbean, Middle-Eastern populations have higher than average risk of Type 2 diabetes – Poor quality of care received by less affluent and socially excluded people, e.g. prisoners, refugees, people with learning disabilities or mental health problems Complications – Diabetics have higher emergency admissions than the general population from complications - coronary heart disease, stroke, peripheral vascular disease, kidney damage and failure, infections and other conditions Local Situation Local diabetes prevalence • 18,878 diabetics in Ealing (4.97%), 7,773 in Southall (6.97%) • 29% of Ealing’s population live in Southall, but 41% of diabetics live in Southall • 1,413 diabetic patients from shared practice population of 17,350 (8.14% prevalence, April 2010) • Ethnically diverse population in Southall • In Ealing, Emergency admissions rose by 95% between 2003/04 and 2008/09 The Project PCT Project Group Southall Pilot Practices 1. Oversight of Southall project 1. Two patient consultation workshops 2. Link with Ealing-wide developments for diabetes 2. Baseline data assessment 3. Specialist Diabetic Clinic to enhance practice systems 3. Link with hospital-led diabetes care pathway improvements 1. Patient Consultations 55 diabetic patients from all pilot practices participated in two workshops. Patients strongly recognised the important role of general practice as a source of advice and information Patients want: • More support and encouragement to manage their own condition • Patient support groups • More patient education about – – – – Medication Diet and cooking for entire family Foot care Exercise 2. Baseline Data Assessment • We looked at the QOF data as a group and found that we were very good at recording: – – – – – – – – BMI, retinal screening, peripheral pulses, neuropathy testing, blood pressure micro-albuminuria testing, eGFR or serum creatinine and total cholesterol But: • As a group our HbA1c control needs improvement And: • The exception reporting in some practices is unusually high 3. Specialist Diabetic Clinic to enhance practice systems Clinical Competencies: Knowledge, skills, consultation styles, competencies framework Effective Care Planning: Good control as manifested by HbA1c measurements, negotiated and understood person centred care plans, targeted interventions, goal setting Effective self care: Patient held records, literature for self-help resources, patient education about self-management, education for the wider family Governance: Call and recall systems; protocols for blood and urine tests, systems to capture regular non attendees, language alerts on practice systems Recommendations to Other Practices Recognise key role of receptionists • Training for receptionists so they can advise patients Improve communication during consultations • Encourage patients to bring an interpreter • Include alerts on patient’s notes about interpreter requirements Devise strategy to reach patients that regularly DNA • Receptionists book patients for review opportunistically • Where possible have HCA available for on the spot review 2011 Action Plan 1. Training for all practice staff including receptionists 2. Up to date literature in a variety of languages 3. Continue close working with diabetes specialist nurse 4. Monthly meetings inside practices and quarterly meetings of whole group to oversee developments and communicate findings to the GP Consortium Recommendations for the Future 1. Expand links between the Southall Initiative and Ealingwide strategic developments 2. Develop the Intranet to support decision-making for diabetes care 3. Continue to gather data to scrutinise performance across Southall Recommendations for the Future 4. Scrutinise and pilot improvements at each stage of care pathway • • Screening – who to target and how? Entry into the system – the newly diagnosed diabetic (including emotional support) Care planning – goal setting, treatment plans, monitoring, review Involvement of/referral to extended team members – dietician, specialist nurse, eye care, self help groups, education programmes • • 5. Improve practice skills at dealing with depression in diabetics Acknowledgements Pilot Practices (GPs and other practice staff) • • • • • • Health promotion Centre Northcote Medical Centre Somerset Medical Centre St George’s Medical Centre Sunrise Medical Centre The Town Surgery Diabetes UK • Roz Rozenblatt Wider team • • • • • • • • • • • • • • Harpal Rai (and DSN team) Dawn Stewart (and Podiatry team) Diljit Sidhu (and Dietetics team) Dawn Karim Jo Snowden Louise Taylor Rachel Krausz • Dr Kevin Baynes Gilly Stoddart • Dr Sanjeev Mehta • Satty Aulakh-Clarke Paul Thomas • Laura Windebank Debbie Kelly Sapna Chauhan • Dr A K Sandhu Sheelah Watson • Dr P J Sandhu • Dr Sandar Cho Raj Swaris • Cyprian Okoro Sylvia Parry Southall Initiative for Integrated Care 2009-2010 Support for Children & Families Camille Adams Mary Ford Sumarah Iqbal Dr Qadan National Situation Between 1999 and 2009 the Government published over 20 policies relating to the health of under fives Key points: • An increase in Childhood Obesity prevalence • Factors affecting the health of children include lifestyle, socio-economic, cultural and environmental factors • A decrease in the uptake of MMR from 93 to 89% • The need for local services to work together to improve the health of children • The need to increase the level of GP engagement in delivering high quality care for children and their families The Project 1. Rapid appraisal including perspectives of a) GPs, b) Local support agencies for children and families c) Public Health 2. Develop a Children and Families Directory for general practice 3. Support practices to refer to MEND and SAFE 4. Support practices to act on their ideas for improvement 1. Rapid Appraisal General Practice Perspective • • • Agreement that social needs affects physical health, but no easy way to refer to, or work with other agencies Insufficient awareness of what different agencies offer Need for guidelines for referral and easy self-referral Perspective of Voluntary Groups and Children’s Centres • • These groups are (unlike general practice) well informed about the range of services that can support children and families Children’s Centres staff are keen to work in partnership with a range of health colleagues including general practice Public Health Perspective • Several initiatives operate to improve the wellbeing of children and families, e.g. MEND and the Childhood Immunisation Programme 2. Directory of Local Services 3. Referrals to SAFE Number of referrals to SAFE Referrals from Health Professionals to SAFE GP Health Visitor Other 225 18 200 16 175 14 Number of Referrals Number of Referrals Unknown Health Professional Non Health Professional 150 125 100 75 50 12 10 8 6 4 25 2 0 0 April - Sept 2010 Other Dr Midwife Unknown April - Sept 2010 4. GP Achievements • Increased awareness of need. Now approx. 2-3 times each week GPs direct patients to receptionist for further information about a service • Increased awareness of need for self referral - patients are very happy to self refer 4. Receptionist Achievement • Increased knowledge about local support for children and families – Visited local community groups to establish relationships – Used the Children and Families Directory – Handed out literature in the surgery Recommendations to Other Practices 1. Develop receptionist to keep up to date information about local support for children and families • • • Display posters and leaflets about e.g. domestic violence, housing, isolation and depression, drop-in centres for children, nurseries, playgroups, debt advice Hand out leaflets Outreach 2. Visit and befriend local support services 3. Invite leaders of local services to visit the practice and continue debate about collaborative improvements 2011 Plans 1. Each cluster practice will continue present success areas: • • • 2. Develop reception as information repository with a lead receptionist Monitor referrals to MEND, SAFE and other services for children & families Build relations with schools and other agencies Cluster practices will meet together quarterly to oversee: • • • 3. Recommendations to Southall practices Support the PCT in developing the Intranet and coordinated data gathering Collaborative working with school nurses, health visitors and others Need to do a rapid appraisal of new issues that have become priorities: • • Domestic violence Partnership e.g. with school nurses to improve immunisation uptake Acknowledgements • SAFE – Nick Bidmade – Chantelle Antoine • General Practice – – – – – Dormers Wells Medical Centre KS Medical Centre Chepstow Gardens Medical Centre The Saluja Clinic Southall Medical Centre • Children’s Centres Project Manager, Southall • Shilpi Mehra Southall Initiative for Integrated Care Nov 2009-2010 Dementia Lynne Read, Sujoy Mukerjee, Frances English, AK Sandhu National Situation National dementia strategy and NICE decision to treat Alzheimer’s at an early stage have refocused attention on dementia care. Early dementia diagnosis is desirable because: 1. Anticholinesterase inhibitors can help ~20% of patients with dementia 2. Diagnosis permits family conferences to plan coordinated care, e.g. writing advanced directives when a patient is still able to make informed decisions. This reduces need for institutionalised care 3. Diagnosis provides impetus to preventative efforts including control of diabetes & hypertension, and attention to problem drinking & good mental health 4. Diagnosis helps access resources for patients and carers Local Situation Expected numbers of patients – Estimated number of people with dementia aged >65 = 5% – Number diagnosed on Southall GP registers = 289 – Expected number of patients on GP registers = 498 The CMHT asked pilot general practices their views: – – – – The referral form for dementia is cumbersome Help with acute dementia crises is slow and unreliable What happens to referred patients is not clear Uncertainty when and how to screen for dementia, especially in languages other than English – Uncertainty of what practical help can be offered to patients & carers The 2010 Project 1. a) Audited the number of patients with diagnosis of dementia on GP Computer systems, b) Audited numbers of patients referred for memory decline from pilot practices 2. a) Improved the referral form for patients with suspected dementia, b) Revised procedures for supporting GPs with a difficulty, c) Developed a new memory clinic in William Hobayne Centre for patients aged under 65 3. Translated the Mini Mental State Examination into Hindi and Punjabi 4. Worked with partners to link the Southall work into an Ealing-wide strategy for 2011: a) Dementia Concern, b) General Practices E85743 E85733 E85721 E85656 E85623 E85103 Y01221 E85745 E85731 E85717 E85682 E85671 E85663 E85633 E85121 E85119 E85096 E85090 E85083 E85061 E85051 E85049 E85023 E85012 E85006 Number of dementia patients per 1000 patients 1a. GP dementia diagnosis audit Number of dementai patients per 1000 patients for Soutall Practices 30 Pilot practices 25 20 15 10 5 0 1b. Dementia referral audit Referral for memory decline Practice Number Practice Nov 2008-Nov 2009 Nov 2009-Nov 2010 E85717 Western Road Surgery 1 0 E85006 Waterside 1 1 E85049 Belmont Medical Centre 1 1 E85090 Hammond Road Surgery 2 1 E85061 Norwood Road Surgery 2 3 Y02342 Bondcare N/A 4 Note: Bondcare established in April 2010 4a. Dementia Concern • DVD on dementia in different languages • Able to befriend and support • Drop in Centres • Multi-lingual staff 4b. General Practice • Patients and families know and trust GPs • GPs can screen at an early stage • GPs can prevent deterioration of dementia by controlling blood pressure, diabetes and stress • GP recall systems can help follow up patients Recommendations to Other Practices • Screen & Refer • Monitor & Recall • Health Promotion Proposals for 2011 • Quarterly steering group meeting to oversee dementia plan in Southall – Embed the referral form on EMIS computers – Audit referrals from all Southall practices – Audit numbers of patients with dementia, number and cost of unscheduled care (including admissions) by practice • Develop a ‘Supporting Dementia at Home Pack’ – For families and carers as well as individuals – Information about making wills, family conferences, end of life planning, posting Special Patient Notes, advanced directives – Tactics to support someone with dementia at home • Develop a ‘Primary Care Resource Pack’ – How to identify and refer for dementia, and avoid deterioration – Mini-Mental State Examination in various languages – Facts and Figures, a) Care Pathways and care options, b) Supporting Dementia at Home Pack, c) Posting Special Patient Notes Acknowledgements General Practices Waterside Medical Centre Norwood Road Surgery Belmont Medical Clinic Hammond Road Surgery Featherstone Road Health Centre Western Road Surgery Dementia Concern Community Mental Health Team Southall Initiative for Integrated Care 2009-2010 Helping people of BME background with depression / anxiety Kiran Sharma Dr Mohan Nina Kaler Mohammad Shuja Hoda Mandy Hewey Damayanti Modi Mental Health Statistics • One in four GP consultations have a mental ill-health component. • At any one time one worker in five will be experiencing depression, anxiety or problems relating to stress. • “In general, rates of mental health problems are thought to be higher in minority ethnic groups than in the white population, but they are less likely to have their mental health problems detected by a GP.” (National Institute For Mental Health In England, 2003) Project Overview Aim: • To make it easier for users to access services for common mental health problems, and improve access to psychological services for people of ethnic minority background. Key Challenges: • Ensure good access for all groups • Minimise waits • Match need to skill within stepped care framework • Optimise cost effectiveness • Ensure data collection Accessing the Mental Health and Well-being Service Community Groups Resident in Southall GP Occupational Health Secondary MH Self Referral Formal referral by professional Telephone Assessment Flexible Engagement, Full Assessment & Treatment Project achievements 2010 Provided an integrated service that: • educated patients to be their own therapists, • improved their well being, • reduced the risk of recurrence and • promoted social inclusion. Increased number of referrals from BME groups Anxiety and Depression in Hard to reach groups NHS Ealing and Central and Northwest London Mental Health Trust Project Team INTERVENTIONS DRIVERS AIM Improve accessibility to Mental Health (MH) services for hard to reach groups, including BME groups, Older People and disabled people Key: Ealing site Both sites CNWL site Increase awareness amongst general population Training for Community Centre Staff Health promotion events Liaise with community leaders – link worker Education in the community Community based radio and newspapers Posters in key strategic areas, and business cards Set up website Promoting self-referral Increase number of self-referrals Improve appropriateness & increase numbers of GP referrals Improve client experience GP- prompted self-referral systems set up for receiving and managing self-referrals Ealing Matters & GP magazine Go to Practice Managers meetings Go to Practice Based Commissioning meetings Education of other health professionals GP increased awareness & engagement GP liaison: MHWBS in person in practices GP education & awareness of MHWBS Learning Packs Training of Practice Managers & other staff MH measures translated into other languages and audio Translation Multi-lingual staff Multi-lingual call back service Materials Referrals by ethnicity 2010 100% 90% Chinese or other ethnic group Black or Black British 80% 70% 60% 50% 86% 77% 40% Asian or Asian British Mixed 30% White 20% 10% 0% Core practices 2010 Southall PBC 2010 Ethnicity of referrals: 2009 & 2010 140 120 Number of referrals 100 80 60 40 20 0 White Mixed Asian or Asian British Core Practices 2009 Core Practices 2010 Ethnicity Black or Black British Chinese or other ethnic group Number of referrals: 2008 - 2010 350 300 Number of referrals 250 200 150 100 50 0 Southall PBC 2008 Southall PBC 2009 Year Southall PBC 2010 Recommendations for others • By working closely with the Mental Health and Wellbeing Service GPs can develop relationships and clarify the best use of the services available. • Create a shared ethos of improving mental health and well-being within the community setting for the population of Southall. • Planning services- involve communities and service users. Plans for 2011 • Provide tailored mental health training to all stakeholders, information on referral responsibilities and options. • Work together to prevent and better manage mental illness in black and minority ethnic groups. • Identify gaps in service provision for BME client's through the work of the Southall Initiative and develop local action plans to meet the identified needs. • Develop integrated community based services for mental health. Example work closely with Southall Norwood CMHRC. Acknowledgements Pilot Practices • • • • • • Cecil Road Surgery Guru Nanak Medical Centre Jubilee Gardens Medical Centre Somerset FHP The MWH Practice Woodbridge Medical Centre Southall Team, Mental Health and Well-being Service CLAHRC Tabletop discussions • In what ways might the model be useful to GP Commissioning? • Next steps – Leadership teams meet 8th December at 4pm – ESTAR training January to March – Stakeholder workshop 31st March and 7th July • Evaluation and research