Transcript Calderdale and Huddersfield NHS Foundation Trust Huddersfield & Calderdale Rheumatoid Arthritis Project Integrated Service Improvement Programme Programme Aims To develop the capacity and capability across the.

Calderdale and Huddersfield
NHS Foundation Trust
Huddersfield & Calderdale
Rheumatoid Arthritis Project
Integrated Service Improvement Programme
Programme Aims
To develop the capacity and capability across the healthcare system in Calderdale
and Huddersfield to deliver improvement in service provision and clinical outcomes
to people with Rheumatoid Arthritis and their carers.
Commissioner:
Outcomes
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An agreed model of care for RA and improved evidence based pathways
Comprehensive periodic MDT assessment, in primary care setting
Satellite tertiary care (resistant RA / Biologics) clinics in Primary Care
Enhanced RA knowledge & clinical skills in Primary Care
MDT shared Care Record
Appropriate day case care repatriated from Leeds into HRI
EPP type training for patients & information for patients and carers
Web resource for Primary Care & RA patient community
Benefits
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Improved access to appropriate local services
Reduction in the number of unnecessary follow-ups. Freed outpatient capacity
Reduced variation in how RA managed across LHC
There should be improved consistent information for service users and others.
Commissioners and planners will have better quality information about services
Patients will feel empowered and enabled to self-care
Kirklees PCT
Calderdale PCT
Providers:
Calderdale & Huddersfield NHS
Foundation Trust
Leeds Teaching Hospitals NHS Trust
Registered Population: 420,000
16 LHC Demonstrator Stories on www.networks.nhs.uk
1. Huddersfield & Calderdale Rheumatoid Arthritis Benefits Dependency Network v3.0
Enablers
Work Streams
Outcomes
Benefits
(& Actions to Change)
1. NSF’S/OHOC..
1. Model of
Care/Integrated
Care Pathway
Development
2. Tariff/PbC
2. Staff
education,
training &
development
1. An agreed model
of care for RA &
improved evidence
based pathways
2. Comprehensive
periodic MDT
assessment, in
primary care setting
Pathways
3. Public Sector
Agreement
target for care
plans
3. Revised
DMARD
Protocols
4. Modernising
Information
management &
Technology
4. Care records /
communication
5. Workforce
Development
5. Day Case
Review
3. Satellite tertiary
care (resistant RA /
Biologics) clinics in
Primary Care
4. Enhanced RA
knowledge &
clinical skills in
Primary care
5. MDT shared Care
record
6. PPI / EPP /
Third Sector
provision
6. Self-care &
Patient
Information
6. Day case care
repatriated from
Leeds into HRI
7. EPP type training
for patients &
information for Pts
& carers
8. Web resource for
Primary care & RA
patient community
1. Reduced
variation in how
RA managed
across LHC
2. Improved access
to appropriate local
services
3. Fewer
unnecessary follow
ups. Freed
outpatient capacity
4. Integrated
services for
patients
5. Improved
communication
along whole patient
journey
6. Patients’
empowered and
enabled to selfcare
Priority
Objectives
Measures
• Patients RTT times
• Rheumatology outpatient utilisation data
1. Appropriate
use of LTC
• Clinical Audit data
healthcare
services
• Survey of patient experience and Primary
across LHC
Care staff experience of Rheumatology
Estates
2. Improve and
service to be developed by Picker Europe
maintain
clinical
• Number of patients being seen in
outcomes
community
outreach clinics
3. Promote
greater patient
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Number of patients receiving day case
selfmanagement
treatment within Kirklees & Calderdale
versus number
travelling to Leeds
Comm’s
4. Develop
links with the
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Staff
and
patient
education programme
voluntary
sector, and LA
participant evaluations
where
appropriate
• Availability of web based information
resources for patients and community
5. Improve
based
patient & carer
experience
staff
Progress to Date
• Project mapped to national strategy and local drivers
• Commitment from PCT Chief Executive Board Sponsor identified
• Resources identified
• Work stream leads identified and briefed
• Project PID completed
• Project Gantt chart developed
• DMARD Protocols reviewed and revised
• Rheumatology Project Manager appointed
• Day case service activity data collated and analysed
• Draft business case for day case repatriation
• Specified patient pathways mapped
• First release HQ software (messaging and diary functionality)
• Level 3 Service Model drafted and tested
Key Milestones: September / December 2007
• Piloting of multi-disciplinary ‘MOT’ clinics (September)
• Evaluation of the compatibility of the full suite of HQ software with the Intel Mobile
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Clinical Assistant
Revised ‘Shared Care’ protocols
New role definition for specialist nurses (in light of MDT ‘MOT’ clinic evaluation)
Staff ETD requirements determined
Patient management functionality on HQ software
Local Contacts
Dr Richard Reece – Consultant Rheumatologist
[email protected]
Dr Simon Holmes – Project Manager
[email protected]
Mr Peter Rogers – ISIP Change Consultant
[email protected]