Integrated Care Services (iCares). Transforming and Integrating Community Services within admission avoidance, care management and community rehabilitation services

We used the opportunity of a Department of Health Quality, Innovation, Productivity and Prevention (QIPP) Long Term Conditions project to apply the evidence base for long term conditions management to our problem.

The issues / problems being; increasing demand, reducing resources and staff, numerous points of access, part time admin staff so use of answer machines and message books, paper notes, bulging filing cabinets, handovers and gaps in care as pathways were disjointed and impossible to navigate for staff.

The three main themes of this are:

1. Integrated locality teams.
2. Risk stratification of population.
3. Systematic implementation of self-care and self-management.

Patients with long term conditions and/or neurological impairment rarely present with one aetiology and often require the intervention of both health and social care, particularly during a period of crisis or deterioration.

Redesign assumptions

• Involvement of senior decision makers early in the process result in a more timely assessment, tighter care planning and less time spent in statutory services (which illustrates NICE NG74 recommendation 1.3.1).
• Service users and commissioners want to use a single point of access (which illustrates NICE NG74 recommendation 1.2.2).
• Services should be responsive to the patients needs at the time of referral irrespective of setting or aetiology.
• Processes and systems should be lean across organisational boundaries, reducing duplication and providing efficiency.
• Integration of services to meet Quality, Innovation, Productivity and Prevention (QIPP) agenda for long-term conditions (LTC) and deliver the best high quality care.
• Self-care and self-management should be embedded into every contact and care plan.

Aims

• Further deliver the care management specification.
• Deliver QIPP LTC agenda of integrated teams around a locality.
• Meet increasing demands and increasing complexity of care.
• Make cost savings.
• Ensure CCGs receive a service they will commission into the future.
• Be a provider of choice.
• Develop care for the next five years.

We faced a perfect storm in 2012: increasing demand with patients who were increasingly complex. Sandwell is the 12th most deprived local authority in England, with over percentage 65s forecast to increase significantly by 2025. The main causes of death are circulatory diseases (coronary heart disease, stroke), lung cancer and chronic respiratory disease.

Data from NHS England (http://ccgtools.england.nhs.uk/ccgoutcomes/flash/atlas.html) shows that health outcomes for the population of the CCG is in the worst quartile for almost all indicators in four of the NHS Health Outcomes Framework.

The last census information shows 60% of the population live in deprivation with 30% of children living in poverty and 21% of the population rate themselves as having a long term illness. There is c. 320,000 people resident in Sandwell.

Locally we were faced with:

• Long waits for routine appointments (40+ days).
• Part time administrative staff and answer machines.
• 6% cost saving target.
• Commissioners wanted something different including more responsive services. Specifically they sought a single point of access, joined up services that delivered more admission avoidance, reduced readmissions and reduced waiting times particularly for those patients leaving hospital.
• Users wanted less complexity and one point of access. Users told us that they didn’t get to see a senior or specialist clinician if they had complex needs either at all or soon enough and were passed around between staff and teams. If they did manage to see a senior clinician they had to retell their story and then the plans made with them kept changing. In addition, they couldn’t navigate our teams and system and had examples where staff couldn’t do this either. This contributed to delays in care and missed opportunities to maximise potential recovery.
• Paper-heavy bureaucratic processes.
• Low staff morale.

We listened to the feedback from users and staff about how hard it was to navigate pathways and faced the reality that with decreasing resources and increasing demand, the status quo could not continue. The evidence base was guiding us towards integrated teams so we used the outputs form the DH QIPP LTC work stream to inform a high-level strategy.

From there we started staff engagement and via the listening into action was honest and open about the future challenges we faced. We asked for staff, leadership and union support to remodel what we did.  We then set about auditing everything we did, who did it, how long it took and challenged whether it could be done more efficiently to benefit patients and staff.

As a leadership team we identified a high level model to meet the future state vision.

This future state would see that:

• Current teams will be integrated.
• Referrals will be received and triaged irrespective of aetiology.
• The clinical decision making at triage will aim to match clinical need to clinical competence ensuring a timely service with senior decision making early.
• Referrals will be categorised as unknown, unpredictable and predictable.
• No clients will stay in the service for life; repeated access to meet needs will be the norm as condition changes.
• Self-management and reablement episodes of care are core to service delivery (This is aligns with NICE NG74 recommendations in section 1.1 on the core principles of intermediate care including reablement).

We used the Kotter’s change management model and embarked on a six month change programme. This included staff and stakeholder engagement via listening into action events, working parties and market place events.

A new standard operating procedure was written with the help of all staff. Understanding and supporting the culture and values of teams, learning styles and change were critical to the change process, with a heavy use of Fishers Change Curve. Leadership was critical to taking every on the journey.

The main challenge was staff fear which we overcame through:

• conscious and deliberate open and honest communication
• proactive leadership support for all staff with an open door
• the Fishers change curve was shared and used with all staff. This reinforced the idea that whatever you are feeling now is normal and we are all going to feel it so how can we support each other to move on with this current feeling

The comms strategy was reviewed fortnightly and every method of communicating with people was employed - bulletins, newsletters, emails, open door, staff meetings, lunches. Formal management of change embedded changes to T&Cs including hours of work, line management structures and bases for working.

The new service was launched on 1 October 2013 and was only 80% “right”. We have used a PDSA cycle since then to evolve and continuously improve what we do. Five years after launch the service continues to meet increasing demand, has maintained its response times and has met all 8 of its original aims.

Evaluation has focused on:

• Response times
• User feedback
• Staff feedback
• Length of stay in service and community beds
• Referral management
• Readmissions.

Main Results:

• Single point of access and no answer machines.
• Open access for life.
• No referral forms.
• Very few criteria for access (any adult 16+ who needs admission avoidance, case management or community rehabilitation irrespective of diagnosis or location).
• Triage at point of referral to determine users’ needs with the user.
• No waiting lists.
• Appointment given at point of triage matched to the most appropriate professionals to meet their needs.
• Integrated locality teams delivering joined up care.
• Inter professional working and competences.
• Service now seven days a week.
• Urgent appointments within three hours, routine appointments within 15 days.

Impact - outcomes and benefit:

• Its easy to navigate.
• Users love it and we are meeting their needs.
• Access via a single point and open access for life - no criteria, no barriers to getting in. As a patient or carer just give us a ring and you can come back at any time.
• Response times - urgent nurse/rehab appointments within three hours, seven days a week. Routine appointments within 15 days.
• Patient satisfaction - 98% of patients would recommend the service to their friends and family. (c. 1500 questionnaires per annum).
• Staff satisfaction - 88% of staff feel involved in decisions and changes.
• Outcomes - 90% of patient sets goals are achieved or part achieved. (c. 3600 patients reported goal attainment per annum reported).
• 93% of people stay in the community after an urgent visit rather than being admitted to hospital.

Cost savings:

Annually between 6% - 3% mixture of pay and non-pay achieved through productivity and skill mixing.

Efficiency and productivity gains:

• Meeting increased demand, taking on new projects and contributing to research with some additional funding but not enough to account for total increased activity.
• 50% increase in admission avoidance activity.
• Contribution to 2% reduction in readmissions.
• New roles including assistant practitioners.

New models of care:

- 'Own Bed Instead' - intensive rehabilitation / intermediate care at home for four weeks.

- 'Bridging the Gap' - Agewell Community Interest Company (CIC) delivering rehabilitation programmes and post-NHS care with reducing length of stay in rehab unit and reducing readmission rates.

- Care homes dysphagia champions - reducing referrals to speech therapy as care homes manage their own simple referrals.

• Hindsight has taught me how important it is to embrace the journey and make sure everyone is involved. You cannot cut corners.
• Integration is about a set of behaviours and principles rather than a structure or standard operating procedure.
• Understanding my own personality type has been essential to understand how I “land” and effectively support the team in times of change. It has also meant I actively seek out those with a different style who will challenge and support me to be a more inclusive and effective leader.

Remember: 

• Taking the first step is really scary. It’s a journey.
• Always concentrate on culture and values.
• The power of patient stories to keep focussed.
• You are allowed to make mistakes.
• It doesn’t have to be perfect.
• You can’t communicate too much.
• Ask for help and don’t reinvent the wheel.