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Bradford South & West Programme of work 0708

By Anna Murphy,2014-07-11 16:53
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Bradford South & West Programme of work 0708 ...

    July 08 Commissioning Update Clinical Exec

    APPENDIX D

    July 08 Progress Update on Bradford South & West Commissioning Plan

    1. Reducing emergency admissions

    Service area Development Proposed Investment Progress Health forecasting for COPD System purchased, set up costs split between ? Purchase of automated system based on 3,435 COPD

    patients 3 alliances (YPCA not participating) patients (as at Mar 07).

     Public Health has data re. no. of patients Use of automated health forecasting which dictates cost of system. systems as supplied by the Met Office

     Evaluation in progress to determine impact

     and whether to re-commission

Enhancing fast response team Additional investment to be funded partly ? 2 additional support worker posts per night, 7 nights per week,

     through alliance pooled FUR covering 10 hours

    Increase capacity in Community ? 1 full time Physiotherapist

    Support Team (Fast Response) Recruitment commenced, service ? ? time OT

    introduce therapy and Nurse specification drafted and in final stages, ? 1 full time Nurse Practitioner Practitioner role pathway agreed, anticipate service to be at ? Redesign of present NP cover in community hospital service full capacity by October 08. to provide out of hours NP cover across whole intermediate

    care services

    ? Telecare package for S&W population

    ? 4 6 extra patients supported per night with planned visits

     - 1 -

    July 08 Commissioning Update Clinical Exec Developing integrated community Additional investment to be funded partly ? Redesign existing Community Matron system

    support teams and the community through alliance pooled FUR ? 11 additional Community Matron posts (17 in total) & 1

    matron role Community Support Worker (2 in total)

     Additional Community Matrons recruited to ? Each Community Matron covering a population of 8,000 to

    Development of practice based provide 12 Community Matrons in total 10,000.

    integrated community support teams across S&W covering a population of approx.

     14,000. Service specification drafted and in Development of current Community final stages, pathway and implementation Matron roles and increase in numbers plan agreed, anticipate service to be at full

     capacity by September 08.

    Additional support requirements based on the

    low Community Matron recruitment figures to

    be evaluated 6 months into the start of the

    service.

    Working with district nursing teams and social

    care managers to develop integrated team

    approach

Screening of patients with No impact on FUR, practices will pay local ? Cost per patient of ?180

    suspected DVT tariff.

    Referral of patients with a suspected DVT to community team for screening Service up and running.

    2. Improving access to mental health problems

    Service area Development Proposed Investment Progress Primary Care Gateway Service Additional investment to be funded partly ? Increased capacity for Counselling and therapy

     through alliance pooled FUR ? Increase in the number of mental health practitioners

    Reconfigure current team and ? Increase the overall primary care service by 12.5 sessions per

    increase number of practitioners in Recruitment commenced, service week (43 hours)

    order to increase sessions to near specification drafted and in final stages,

    national recommendations pathway agreed, anticipate service to be at

    full capacity by July 08.

     - 2 -

    July 08 Commissioning Update Clinical Exec Improving identification and Awaiting commissioning plan. ? Will be informed by the recommendations from the district

    support for patients with Dementia wide commissioning plan being developed following the

     review.

    Improve practice registers, develop

    pathways into services and utilise

    existing services better

Primary care based alcohol misuse District wide service review ongoing, roll out ? Expand provision of Allerton service across the Alliance

    support of Allerton project part of plans ? Estimate 5 WTE support workers covering a population of 25,000 30,000 each Identifying and supporting patients with a drinking problem

Social prescribing (CHAT) Additional investment to be funded partly ? Estimate 5 WTE support workers covering a population of

     through alliance pooled FUR 25,000 30,000 each

    Improve access and availability of

    CHAT service to patients in S&W to Recruitment to commence in July from improve mental wellbeing of patients existing pool of Health Trainers, service with psychosocial needs specification drafted and in final stages,

     pathway agreed, anticipate service to be at

    full capacity by September 08.

    3. New developments

    Service area Development Proposed Investment Progress Falls Proposal being developed, linking in results ? 1 Falls Liaison Nurse

     of recent PCT provider evaluation. Reduce the number of falls through

    direct support to patients and

    informing and educating primary,

    community and secondary care

Community Midwifery Proposal being developed to commission ? 2 Community Midwives initially supporting patients in the

     service from Calderdale, linking into district-Wyke locality working with the Wyke Children’s centre

    Improve the continuity of care for wide Maternity Network. patients choosing Calderdale for delivery, pilot both case loading Initial discussion with LA re. delivering pilot

     - 3 -

    July 08 Commissioning Update Clinical Exec approach and working with Children’s with/in Wyke Children’s centre, meeting with Centres to deliver integrated services Children’s Centre management, practices,

     and LA end of July to progress.

Pain Management Initial review of services ongoing, models to ? Community based pain management services linking into

     be developed for delivery by the end of the district wide MSK pathway

    Develop community based pain year. management services

Obesity 2 weight management pilots being run by 2 ? Slimming World, Weight-watchers and Weight Management

     practices schemes to assess their effectiveness for weight management

    Reduce levels of obesity and improve across the alliance population

    weight management

    Cardio vascular disease Proposal being developed. ? Primary care based risk assessment service aimed at those

     patients at risk of CVD

    Reduce the number of cardio vascular S&W practices agreed to adopt development ? Working with Community Development workers to target hard

    events for patients at risk primary area as the alliance indicator in PBC to reach patients that do not normally access health services. prevention incentive scheme.

Cardio vascular disease Proposal developed. ? Web-based risk stratification tool and lifestyle support service

     to be piloted

    Reduce risk of stroke for patients with 2 practices to pilot commencing by

    Atrial Fibrillation September 08.

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    July 08 Commissioning Update Clinical Exec

    July 08 Progress Update on PBC/ YPCA

    Service area Development Proposed Investment Progress Older People Mental Health Memory Assessment Pathway (early Diagnosis of Dementia). Working in close partnership with the District

     wide initiative, the Mental Health Care Trust

    and the LA and fitting the memory

    assessment pathway in with the "footprint"

    identified in the recent OPMH district wide

    review and the workshop outcomes.

    Anticipated start date autumn 2008 Older People Increase the number of case managers by 6 ( TOTAL 11) CASE MANAGERS will work closely with

    CIT, Pulmonary Rehab, Falls Co-Ordinator,

    CHD specialist practitioner nurses, Care

    Homes, etc (with a pathway towards

    becoming Community Matrons as part of

    their CPD). Mental Health Increase the number of gateway workers by 3 The gateway workers will be supported by an

    increase in Self-Help, CBT and Counselling

    services. Teenage Pregnancy and Sexual Improve services in localities with high prevalence STD/Teenage Working closely with Clare Livens in Health (TPSH) pregnancy supporting the district wide initiatives and

    plans.

    Spreading the HOTS project will be part of

    the TPSH work Obesity Slimming World, Weight-watchers and Weight Management Pilots ongoing

     schemes to assess their effectiveness for weight management 2 weight management pilots run by YPCA

     - 5 -

    July 08 Commissioning Update Clinical Exec

    across the alliance population. practices

     Atrial Fibrillation, Alcohol and for future development of YPCA plans.

    Substance Abuse and Urgent Care

    Whilst the agreement has been reached at alliance level to progress these business plans, 100% agreement across all the practices to pool their FURs in financial support of these initiatives remains to be achieved

    Longer term - once these plans are in place and working, there will be a need to fully support the start of these initiatives with VCS, Carer support, Social Services etc. to ensure complete and seamless packages of care for patients on each of the above pathways. There is also a requirement for end of life

    plans and Care Home plans, as an addition for the Dementia patients and carers, as well as intermediate care for both OPMH and OP.

    July 08 Progress Update on PBC/ CITY

    Service area Development Proposed Investment Progress Obesity Slimming World, Weightwatchers and MEND schemes to assess Pilots ongoing

    their effectiveness for weight management.in our population. 2 weight management pilots run by citycare

    practices

     Intermediate care services Extension of intermediate care services to cover all practices

    through

    ? additional community matrons,

    ? more support workers at night in the hospital at home

    team

    ? additional language support workers to support both

    community matrons and hospital at home.

    Therapies delivered closer to home Additional counselling sessions for Alliance practices Approved

    Increased direct access physiotherapy available to practices Pending

    Citycare priorities for 2008/09 are to reduce health inequalities by concentrating on reducing Infant Mortality and secondary prevention of CVD. Detailed plans are yet to be produced, but there will be a significant investment in community development roles to support both these projects.

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    July 08 Commissioning Update Clinical Exec

    July 08 Progress Update on Airedale & Wharfedale Alliance

    Service area Development Proposed Investment Progress Intermediate Care - ?500K investment in a community rapid intervention team, with a Working towards implementation

     single point of contact

     - Developed community pulmonary rehabilitation programme Implemented

    Mental Health - ?72K invested in expanding the community counselling service Working towards implementation

    and gateway mental health workers

    Therapies - Developed local podiatry services in Addingham Implemented

    Primary Care - Developed a Domiciliary Phlebotomy Service to bring care Implemented

     closer to home

     - Developing a community based anticoagulation service Working towards implementation 4

     practices expected to start delivering service

     from 01/11/08

     (Delayed due to waiting list for Birmingham

     University training course)

     - COPD forecasting project in collaboration with the Met Office Implemented

     - A&E poster campaign and radio coverage to prevent Implemented

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    July 08 Commissioning Update Clinical Exec

     unnecessary A&E attendances

     -2 practices in Keighley and 1 practice in Burley in Wharfedale Implemented

     participating in Weight Watchers / Slimming World Obesity pilot

    Primary Care - Developing Social prescribing (CHAT) to improve well being of Bid going to CMB in July

    patients with psychosocial needs

    Sexual Health - Developing community based sexual health and contraception Several practices keen to deliver but waiting

    services for availability of training & clinical sign-off Ongoing development work:

    Service specifications and business case being developed to form a 'Community Collaborative Care Team', to include: - an expansion of current Community Nursing Team to include Physiotherapists, Occupational Therapists, Community Physicians and Social Workers - the expansion of community matrons from 2.8 WTE to 7 WTE

    - a falls management/prevention service

    - a community children's service, to provide care to children in their own homes and schools, thus reducing hospital admissions and reducing the psychological effect of hospitalisation and care in a clinical setting

    - introduction of Telecare & Telehealth into the community in collaboration with secondary and social care.

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