The Long Term Conditions Pathway Transformation in Central Lancashire

Transcription

1 The Long Term Conditions Pathway Transformation in Central Lancashire Vision and Blueprint Version 3-22 March 2013 Document Author: Paula Garstang Programme Lead: Paula Garstang Page 1 of 22

2 Blueprint A Blueprint is one part of the documentation used to define a programme of transformational change as defined in Managing Successful Programmes (MSP). It articulates the future state in more detail than the high-level vision and, once approved, is one of the core inputs to detailed programme and project level work definition and phasing. This blueprint is focused on the end of the Long Term Conditions Pathway Transformation (CL) Programme and describes the future model to be delivered by 28 February It should be considered by decision-makers in conjunction with the Vision, Benefits Map, Benefit Profiles and Business Case and emerging plans for the programme these are all linked, and should have coherence in terms of the strategic logic, and funding for the programme. Page 2 of 22

3 Background Many people who receive both health and social care support have to cope with several sets of professionals coming to see them, asking similar questions and assessing them for many of the same conditions and problems. Most of these people are living with one or more long term conditions and many are elderly. In some parts of the country, health and social care teams have begun to work closely together in a more integrated way. They have found that this more streamlined, joined-up approach often results in services which patients and carers say are better for them and fewer people ending up in hospital or in long-term residential care. Locally this has included involving the wider offer of the VCFS and Asset based community development. Long-term conditions already account for 70% of health and social care costs, As health and social care organisations we need to take an increasingly integrated approach to looking at how services can meet the needs of older people and those with long-term conditions more effectively, to provide quality care at home, reduce unscheduled hospital admissions and reduce length of stay in hospital. These are key outcomes required from the Long Term conditions pathway transformation in Central Lancashire. Working more closely together will allow us to achieve a better understanding of how multi-professional teams can support people holistically for example, staff have been (and will continue to be) encouraged and empowered to identify gaps in services and potential solutions for doing things better in the interests of the people they support. In addition, staff will be aware of the needs and choices of the people they work with, and will be able to link them into appropriate services in their own local communities. Maximising local community assets and resources can have a significant impact on living well with a long term condition. Working in a more integrated way will help us to minimise delays, reduce duplication or fragmentation of services, reduce the number of different professionals who need to be involved (so people don t have to keep repeating the same information to different staff), and ensure that information is shared between different professionals more effectively to create a smoother, more streamlined experience for the individual. Page 3 of 22

4 Timelines (to date) in Central Lancashire. August and September 2012: A Programme initiation document was presented to Central Lancashire Clinical Senate in Clinical senate members agreed to fund this large scale change programme including pump priming funding. September- December 2012: Further discussions around funding undertaken. Final funding agreed for Programme management costs. January- February 2013 Funding confirmed by Greater Preston and Chorley & South Ribble CCG (Jan) Programme Manager commenced in post. Series of multi-agency planning workshops undertaken to inform future model of LTC care and management. March 2013 Proposed Vision and Blueprint for LTC care prepared and to be reviewed for authorisation at CL Clinical Senate. Programme recruitment underway, advertised across partnership- Project Managers, Public and Patient Involvement Lead, Programme administrator. April 2013 Final metrics around CL LTC model agreed. Early adopter sites commence as Virtual MDT, working in three of the proposed eleven neighbourhoods. Teams will work with GP Practices in those neighbourhoods to undertake MDT review of high risk patients (identified through risk stratification) and work with patients on anticipatory care plans/ advanced care plans. This virtual approach will also inform the future model requirements in terms of what additional services/ activities are required in the community setting to support admission avoidance. Preparation of Main Access Point Project including scoping current referral methods/ forms and agreement of which services will be included Page 4 of 22

5 High Level Programme Plan The Long Term Conditions Pathway Transformation in Central Lancashire - Vision and Blueprint '! " #$ ( )"( )$ )* +,-.+!! / + ( 0#! "'! % 12) $ % 4,-! #- 2) )! " 6 #$7. % %! : +! ; ) " $.,%.( ( ) # +! &, " 2) $ Page 5 of 22 5!! # %#! &' ( ) ),.+!! + ( 0#!3! % '&2) $ 0 % 4,- 5, 0 3! % '&2) $ 8 #. % %!3! % '&2) ) )! % 0!. # # ( ) + ( 0#! 2) # ),.+!! 0 % 4,!! # 2)) +! + % 0! 7!!!

6 Our Vision A whole system approach that changes things for a generation- People are supported and enabled to stay healthy, and avoid developing a long term condition. Individuals with long term conditions are supported to stay well, with the focus as much on prevention as on the acutely ill. We will deliver this through: A Main Access Point - A central point of contact for referring patients, clients and service users for access to quality assured health information, self-care / self-management advice and support, bookable ambulatory care services and for rapid response / support from the Integrated neighbourhood teams and a range of specialist services. The use of Risk Stratification The Combined predictive model (installed in GP Practices as part of RAIDR) will identify a list of patients that are at high and medium to high risk of accessing healthcare services. This will assist in preventing disease progression and will allow for interventions to be targeted and prioritised. Integrated Neighbourhood Teams that provide a high quality, integrated, person-centered approach working 24/7 in a responsive and coordinated way to empower people through shared decision making- focussing on a whole person approach to maintain a good quality of life within their own home/ community environment. Enabling Self- Care/ Self-management and shared decision making- Individuals taking responsibility for their own health and well-being, self-managing their own condition including symptom management, adapting to their conditions, and dealing with the emotions arising from having the condition such as anxiety and depression. Self-management support will be delivered as a portfolio of techniques and tools that help patients choose healthy behaviours; and as a fundamental transformation of the patient-caregiver relationship into a collaborative partnership. A new model of rehabilitation -An agreed tiered approach and a redesigned pathway for rehabilitation provision, which provides the range of step-up and step down care to meet the full spectrum of need. Page 6 of 22

7 Planning process In January and February 2013 a series of workshops were held to inform and support the planning of the future model for LTC care and management in Central Lancashire. Invitations were sent widely across all partner agencies, to clinical and operational staff and to voluntary and third sector agencies for a total of eight workshops on three themes: Risk Stratification, Self-care & self-management and Integrated Neighbourhood Teams. The outputs from these workshops have informed the future model of care described in this blueprint. In addition a key recommendation from all three thematic areas was the need for a Main Access Point into Community services. The size of this change cannot be underestimated. It is a large scale change in terms of the level of ambition, the number of organisations involved and the emergent final state. The scale of change is a leadership challenge and will required distributed leadership to deliver the significant process, structure and cultural change. These workshops were the start of that journey in engaging and involving staff in understanding the need for change and being able to influence the final model of LTC care. Figure 1: Large Scale Change As phase 1 comes to an end we have already started to embed the principles of co-production. The next step will for the partnership to continue working together to agree the final model, the financial and activity/ contractual agreements and for operational and clinical staff to begin working together in the early adopter sites to understand the neighbourhood population needs and inform the LTC care model to be delivered with the full roll out of the Integrated neighbourhood teams. Page 7 of 22

8 Services/ Teams to be considered and reviewed as part of the Central Lancashire Long Term Conditions Programme Please note that the review of these services will recommend whether these services become part of the Integrated Neighbourhood Team or are part of an ambulatory care offer running alongside the. Alternatively some services reviewed within this programme scope may be recommended as a Specialist Service but will be reviewed in terms of their delivery offer and the relationships and referral pathways between them and the Community Main Access Point () and Integrated Neighbourhood Teams. Children & Families Services will be engaged in the review of transition arrangements pathway. Lancashire Care NHS Foundation Trust Lancashire Teaching Hospitals NHS Trust Lancashire County Council Community Matrons District Nursing & Tissue Viability Service Domiciliary Physiotherapy Falls Service Intermediate Care (Rapid Response) Longridge Community Hospital Diabetes Services Community Dietetics Chronic Fatigue Service Adult Community Respiratory/ Cardiac Podiatry Community Neuro Service Primary Care MH / IAPT Healthy Lifestyles SSS, A4L, Physical Activity CHESS Discharge planning Continence Services CERS (Referral /Access only) Rheumatology (Referral / Access only) TB/ Blood Borne viruses (Referral / Access only) Older Adult Mental Health services Falls Service Brock Day Hospital Belmont Day Hospital Elderly Care Clinics Barton Ward RPH Bleasdale Ward RPH Rookwood A&B, CDH Crisis Provision (72hrs, 1 hr response) Crisis Light Provision Domiciliary Rehabilitation Residential Rehabilitation Services Long Term Residential Rehab Services Dementia Beds, Broadfield Dementia Advisory Service Stroke Advisory Service In addition, the programme will engage with District Council and Voluntary Sector around the community offer to support self-care and selfmanagement. Page 8 of 22

9 The Long Term Conditions Model in Central Lancashire Patient/ Carer GP Hospital Community Main Access Point (inc. Live monitoring of community capacity) Referral administration Clinical Triage Range of Specialist Services inc IP Comm & AcuteBeds 11 Integrated neighbourhood teams Integrated Neighbourhood Team- Admission/ Readmission Prevention Function (CAP) % of population Care provided by Other Referrers Clinic based treatments and interventions Note: Agreed Clinicians and Practitioners will be authorised to have direct access to a number of services (eg Crisis support) without need to access through. Patients identified through Risk Stratification MDT Review Self-Care and Self- Management Options Self-Care/ Self-Management Community / Voluntary/ Third Sector through Local Area Co-ordination Page 9 of 22 LAC/ VCFS & Community Assets Population with Long term conditions

10 A Community Main Access Point () A central point of contact for referring patients, clients and service users for access to quality assured health information, self-care / selfmanagement advice and support, bookable ambulatory care services and for rapid response / support from the Integrated neighbourhood teams and a range of specialist services. The Community will operate 24 hours a day, 7 days a week and will be based within the Referral Management Centre at Preston Healthport providing the main access point and a local knowledge for all referrals into community services for physical health and older adult mental health services. This will provide a clinical triage point (when required) in addition to accepting referrals from GPs, Hospitals and other referral sources including patients and carers. NWAS can also contact the to contact the relevant service and support non-conveyance to hospital where appropriate. The telephone number will be given to all patients (and their carers) who have an anticipatory care plan/ advanced care plan and they will be advised to contact this number as their first point of contact for community support. This will ensure that patients are directed towards appropriate community services rather than the default position of attending A&E or contacting the GP. The staff will have electronic access to the patient record and care plan so that the patient feels known when they call for support. Staff will be able to advise by telephone or request a visit from the integrated neighbourhood team/ relevant service if required. Alternatively they can directly commission a 72 hour crisis support social care package. The will use the Directory of Services and link to LCC and other Community, faith and voluntary sector services directories so that selfcare options are explored and utilised, linking the caller back into activities within their own community where possible. The Community will also host a centralised live community capacity management system where team/ service capacity can be monitored. Community bed status can also be monitored, and community step up and step down beds booked through this central point. In addition the Community will also act as the control centre for all Telehealth, Telecare and other remote monitoring tools. The Map will link into other systems including - RMC, DoS, and other expert helplines including rheumatology, dental, mental health and County and District Council systems, voluntary sector systems signposting to community support. (There will remain an ability for an agreed group of clinicians and practitioners to refer directly to transitional services, VCFS or Community assets directly if they choose to do so). Page 10 of 22

11 Community (Main Access Point) Organisation Processes Referral point for all community health services in Greater Preston and Chorley & South Ribble- All physical health services and older adult mental health services. One electronic referral form that covers referral to all services Telephone access when electronic referral not possible or to access clinical triage. 24/7 Clinical triage- Direct access to clinician Memorable number 0300 XX XX XX One single assessment document Central Point to access Patient care plan and patient records so that patient feels known and clinical decision making is supported. Control and contact centre for all telehealth/ telecare services. Based at Central office during Mon-Fri hrs Based in evening to be confirmed hrs Base overnight to be confirmed hrs Link with RMC and CCG commissioned Directory of Services Agreed process for referrals accepted from GPs, Hospital, NWAS and Patients (where self-referral is an option, or where the number has been given to patients as part of care plan). Electronic referral processes that covers referral to all services. Telephone access system when electronic referral not possible or to access clinical triage. Instant booking processes for all bookable services e.g Treatment rooms and other clinic based services. Agreed mechanism for call response times and call-back Direct access to other services/ helplines e.g. Mental health helpline, Social care Customer Contact Centre A Single Assessment Process Agreed Clinical triage pathways. Referral instant feedback mechanisms and Referral tracking processes. Processes to directly book community beds for step up and step down. Telehealth 7 day monitoring and follow-up processes to identify at-risk patients and enable early clinical response Cross reference to Project Page 11 of 22

12 Community (Main Access Point)- Continued Technology Telephony systems in place, operating diversion when required. Text appointment reminder service Electronic referral systems Electronic Board- Live Community Capacity System for Community beds and Community services capacity Performance & Quality Governance Dashboard Flag up for patients on care plans/ advanced/ emergency care plans Telehealth web based monitoring portal / Information Electronic access to Care plan including emergency care plan/ advanced care planning- shared by patient and all services. Patients with Care Plan highlighted on, and to other services including GP,, NWAS and A&E, MAU so that these services contact for more information and to support access to community clinician or step up/ step down facilities. Live community bed capacity Live community services capacity including high risk patients (Community Admission Prevention) Electronic access to Telehealth results. A wide range of information to support signposting into self-care resources SC Page 12 of 22

13 Risk Stratification- Identifying those individuals at high risk of hospital admission / readmission The use of Risk Stratification The Combined predictive model (installed in GP Practices as part of RAIDR) will identify a list of patients that are at high and medium to high risk of accessing healthcare services. This will assist in preventing disease progression and will allow for interventions to be targeted and prioritised. Risk Stratification- Anticipating those at risk of hospital admission Processes Organisation Combined Predictive Model LACE Frailty scoring Explore links to social care indicators e.g.- Lives alone, bereavement, accessing social care package Agreed processes for GPs working with to identify patients at risk Agreed processes for GPs and to review patients at risk. Agreed thresholds for patients to be offered anticipatory/ advanced care planning. Advanced care planning documentation Anticipatory care planning documentation Cross reference to Project CCG RS Technology Information Risk Stratification software installed in to all GP Practices in Greater Preston and Chorley & South Ribble. Agreed method of access for team members. Development of social care indicators High risk patient monitoring- Bed board CCG RS Page 13 of 22

14 Self-Care/ Self-Management and Shared Decision making To be effective, the Central Lancashire long term conditions care model must be the result of a true partnership, not just between health and social care staff, but also with people who use these services (along with their families and carers) and the local community in each neighbourhood. The ability to maximise resources within a local community is key to meeting the needs of individuals, families and communities. Achieving the right support, in the right place, at the right time, with the right outcome at the right cost is essential. These 'resources'are more than just commissioned services, it includes what people and communities can do for themselves and each other. This will be a major contribution to the 'wellbeing & prevention'of local communities and is an essential foundation for the new long term conditions care model. This focus on supporting people to become involved in their communities will improve outcomes, health inequalities, develop capacity and resilience and reduce financial impact on long term support needs and primary and secondary care activity. This approach will be embedded by Local area co-ordination - a large piece of work led by Lancashire County Council and one of the enabling sub groups of the CL LTC transformation programme. Personalised care planning is an important proactive intervention that will be embedded into practice in the and. This approach, whereby the needs of the individual are identified through a combination of patient data (risk stratification) and the persons own agenda and personalised needs is established during collaborative care planning consultations. The frequency and follow up are determined during the planning process. Care planning identifies the support and services the individual will need to access to enable them to achieve the outcomes (goals) agreed in the care planning process No one initiative on its own can provide the answer, instead what is needed is an whole system adoption of activities to enable patients to develop the knowledge, skills and confidence to manage their own health. Our care pathways will be organised around enabling selfmanagement and aim to: increase the number of adults making healthy lifestyle choices, increase people s feeling of involvement and confidence to be involved increase people s involvement and ability to participate in decisions about their health reduce the prevalence of unhealthy behaviours (poor diet and inactivity, smoking) improve the service user s level of health literacy and ability to manage their health (activation) reduce hospital readmissions and unplanned service use where lifestyle behaviours and symptom management are key factors Core to self-management support is the training and understanding within the workforce of behavioural change techniques and skills. Training will address underlying attitudes and beliefs of the workforce in relation to self-management. This will improve the effectiveness of interventions and is core to making the changes that are needed to support care planning and shared decision making. Page 14 of 22

15 Self-Care/ Self-Management and Shared Decision Making Organisation Processes Self-care will be a function that threads through the new Long Term Conditions model in Central Lancashire- Helping people to manage the social, emotional and physical aspects of their condition. Partnership opportunities with community, voluntary and third sector colleagues will be maximised to ensure a robust self-care/ self-management offer. Self-Care and Self-Management will be supported by information and signposting from the Community and other agreed access points across the Central Lancashire health economy. There will be a range of structured education programmes available There will be a range of online education programmes available. Health mentors/ Health and Social Care co-ordinators will be available in each of the 11 teams. IAPT Health & Wellbeing Practitioners will be available in each Integrated Neighbourhood Team (). All Community staff will be trained to enable, empower and support self-care. Health coaching will be available on a 1:1 basis, within support groups, by telephone and online. Single assessment of need. Screening for mood Screening for frailty. Information and signposting to a wide range of community resources. Patient preparation prior to each consultation- Access to results, pre-consultation questionnaires. Consultations focussed on patient agreed outcomes and goal setting. Person centred planning approaches will be embedded into practice. Collaborative agenda setting. Patient choice re most effective form of communication- 1-1, phone, text, . Agreed Health mentorship processes. Agreed Health and social care co-ordination processes. Telephone coaching available and processes agreed. Ease of access to a wide range of health and wellbeing services including Stop smoking services, Activity 4 life and healthy eating programmes. Straightforward and responsive transfer of care into functions and Specialist physical and mental health services when required. 24/7 access to equipment. 24/7 direct access to crisis support packages via and also direct for A&E, MAU,, GPs Cross reference to Project / / Page 15 of 22

16 Technology Information Electronic Single assessment document. Electronic patient record. Electronic care plan accessible by patient and relevant professional involved in care. Patient Information resources including Information, advice, patient workbooks including goals, results and tracking. E-Learning opportunities for patients and carers. Downloadable information leaflets A range of podcasts to support patient understanding of medicines management/ symptom control e.g. Mindfulness techniques, Inhaler technique, Breathing exercises etc. Telehealth and other remote monitoring tools Directory of Services Evidence based education programmes Evidence based single assessment documentation and other assessment documentation Monitoring of patients on care plans, when review dates due etc Evidence based information for information leaflets Access to range of equipment and daily living aids available Page 16 of 22

17 Integrated Neighbourhood teams (s) There will be 11 integrated neighbourhood teams and these will be arranged around groups of GP practice populations. Each integrated team will relate to a total population of around 30-45,000. These have grouped a number of natural communities with similar demography/ geography together (See Appendix). The teams will work closely with GP practices to provide care to older people, and those with long-term conditions, including those with complex health and social care needs, to help them live independently in the community. The approach will be broad to ensure the teams meet the needs of adults of all ages, with a wide range of long-term conditions. The teams will include a wider social care offer from VCFS and community assets, facilitated through local area co-ordination. Community Admission Prevention (CAP) function The highest level of intervention from the. Each will manage a cohort of patients at high risk of admission/ readmission to hospital because of complex medical and social needs. They are likely to represent 0.5-1% of the total neighbourhood population served by the team- A cohort of patients per integrated team. These patients will have been identified through the Risk stratification tool in GP surgeries (which also has a predictive risk of readmission) or through clinical decision making. End of Life patients will also be managed within the CAP function. This group of patients will receive multidisciplinary case management and daily review by the link GP for the. Patients will be transferred into and out of this function as their condition deteriorates or improves. If the patient is admitted to hospital or step up care they will be tracked during their stay and supported to an early discharge. An initial assessment will be undertaken by an Advanced Practitioner. Records and Care plans (Anticipatory and Advanced) will be kept electronically so that there is ease of access to information for all professionals (including NWAS via ) involved in the patient s care. There will be access to a wide range of skills from within the team in addition to the right level of social work and pharmacy support including wider social care VCFS and community assets. Page 17 of 22

18 On-going Support and moving into self-care/ self-management The will also support patients with LTC or frail older patients requiring regular (weekly/ monthly) review to support maintenance of good health within their LTC/ older age. This will be delivered through personalised care planning which will support these patients in building their confidence in managing their own conditions and in learning how to cope through periods of ill health/ exacerbation. It is anticipated that these patients will be assessed by an Advanced/ Specialist practitioner on referral into the team. Their care will then be delivered by a core practitioner within the team following the agreed care plan set by the patient and the Advanced Practitioner. The focus will be on the patient developing an understanding of their conditions and linking into a range of self-care and self-management options, including the offers within their own community, wider social care, VCFS and community assets. Early adopter sites Testing out the idea The first step is to set up three virtual s one in each District council area to test out the concept of risk stratification and multi-disciplinary response. This will be done by working with GPs in that neighbourhood to undertake a multi-disciplinary review of those patients identified as high risk. The virtual will undertake assessment and care planning with these patients to deliver a care plan that anticipates likely care needs and emergency care needs. This includes advanced care planning for end of life (See Appendix). The virtual will embed an effective partnership approach. Their work will test out how opportunities for co-location, co-operation and coproduction might bring the anticipated patient benefits and learn lessons prior to full roll-out across Greater Preston and Chorley & South Ribble. The locations of the sites will be confirmed by the start of April Page 18 of 22

19 Organisation Integrated Neighbourhood Teams 11 Integrated Neighbourhood Teams (s) that are physically located in 11 geographical locations across Preston, Chorley and South Ribble. Locations are defined and represent natural communities where possible. The GP practices in those areas are a part of the. Office space in each of the 11 locations, and associated clinic space for carrying out patient assessments (if these are not done at home) and some treatments (specified below) A salaried GP assigned specifically to the s (one per locality) to support CAP function within. s that carry out the following six high-level processes focused on the patient with one or more LTC, not the disease type(s) 1. Work with GPs on risk stratification 2. Assessment of patients 3. Diagnosis and screening services 4. Care planning (goals, outcomes, readiness for change, ability to self-care/self-manage, anticipatory care planning, emergency care planning and (where relevant) advanced end-of-life planning 5. Care coordination 6. Care delivery Operation of the Community Admission Prevention daily board round, prioritised home visits, decisions on needs for community step up beds/ domiciliary rehab support/ residential rehab support. Assessments carried out by s to determine (in no particular order): Vital signs temperature, pulse, blood pressure, oxygen sats Cultural or spiritual needs; Social circumstances Existing medications; Allergies; Oxygen use; Speech; Swallowing; Hearing Skin integrity; Continence;; Existence of and needs of carers; Breathlessness; Frailty; Mobility; Balance; Ability to transfer ; Daily living assessments,falls analysis / potential home hazards; Hydration; Nutrition; Dental or other oral factors; Exercise; Drug use including smoking, alcohol, other recreational drugs; Mood and cognitive screen awareness of changes - risk assessment; Mental capacity for care in the community; Cross reference to project Page 19 of 22

20 Diagnostics/screening carried out by s including:bloods; ECGs; BP monitoring; Urinalysis; Spirometry Care delivery carried out by s including: Wound care; Phlebotomy; IV antibiotics; Anti-coagulation; SC/ IM Injections; Pressure relieving; Administer chemotherapy; Syringe drivers; Adjust medication where prescriptions allow; Relaxation techniques and potentially other psychologically-informed interventions in the home to help the patient self-manage; Personal care at end of life; Provision of equipment (OT); Physiotherapy. Care delivered by s focused in general on managing condition, pain, anxiety, carer anxiety and end-of-life personal care, all focused on the objective of enabling patient with long-term conditions the confidence in the so they do not dial 999, call the GP, attend A&E. Reorganisation of existing 500+ staff into s focused on the patients with LTCs, not disease specific. s will integrate District Nursing; Medicines Management; Community Cardio-Respiratory services; Community Matrons; Podiatry services; Domiciliary physiotherapy; Falls service; Health & well-being services; Mental Health IAPT; Intermediate care and rapid responses services. All affected staff have a new contract and job description, skills passport and ongoing training plan (note: significant training will have been funded delivered as part of the project) Staff roles at three levels: advanced, specialist and core practitioners Management of each undertaken by an advanced/ specialist practitioner (from any nursing/ therapy profession) Each as self-sufficient as possible to cover leave, illness etc Cross team support mechanisms defined Specialist services not included in Integrated Neighbourhood Teams Continence; Discharge coordination; Blood-borne viruses; Diabetes; Dietetics; Rheumatology; MSK physio; Tissue viability; CMHTs (dementia); Speech and language; Dental, LD services. Page 20 of 22

21 Processes Information Technology Integrated Neighbourhood Teams (Continued) Referrals to (including any exclusion criteria) Discharge from Referral from to specialist services not included in Booking of intermediate care beds Transfer of care to other services Changing care pathways (all affected care pathways will have been reviewed and updated as part of the programme) Means of presenting a shared, complete patient records (including care plans and direct access to results from diagnostics) Real-time demand information daily and longer-term (ideally via remote access to GPs risk stratification data) Real-time capacity information intermediate care bed board, services, specialist services Real-time patient condition (tele-health, e.g. oxygen saturation and including texting service) Self-care information on a website, e.g. podcasts on inhaler use, video of how to do a particular exercise Patient and carer experience and satisfaction Shared performance dashboard for service Staff skills records and gaps/training needs capability to monitor within each and across all 11 s Mobile solution to monitor lone working Inventory of equipment and current location linked to calibration records etc Benefit baselines and some early data established see benefits map and benefits profiles 11 offices for s located as far as possible in a central place for each natural community and that are accessible (can get there by public transport, can get in if disabled) and with required IT, telephony, furniture, kitchen etc Associated treatment rooms for s that are fit for treatment. Note: justification for any move of specialist services will be made as part of the programme ideally all services co-located in an community) A means of funding 24/7 s on an ongoing basis A means of funding equipment (e.g. sphygmomanometers) for use and their calibration on an ongoing basis A means of funding some drugs (e.g. antibiotics) for administration on an ongoing basis Ongoing costs defined and agreed Cross reference to project IT IT IT SC/SM SC/SM IT Page 21 of 22

22 Page 22 of 22 The Long Term Conditions Pathway Transformation in Central Lancashire - Vision and Blueprint