DRAFT: NORTH WEST LONDON INTEGRATED URGENT CARE SERVICE

Transcription

1 DRAFT: NORTH WEST LONDON INTEGRATED URGENT CARE SERVICE Document title Service Specification for the North West London Integrated Urgent Care Service: 111 out of hours service Document Draft status Document 2 version Issue date 18 th March 2017 Prepared by NWL NHS 111 Programme Board Integrated Urgent Care Specification Task and Finish Group SCHEDULE 2 THE SERVICES A. Service Specifications Mandatory headings 1 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement. All subheadings for local determination and agreement Service Specification No. Service Commissioner Lead Provider Lead North West London Integrated Urgent Care Service TBC TBC Period March 2017 March 2020 Date of Review March Population Needs Introduction 1

2 The North West London Collaboration of Clinical Commissioning Groups are currently re-shaping their NHS 111, GP Out of Hours and wider urgent care services with the aim of commissioning a functionally Integrated Urgent Care System.. This will provide a single entry point for patients with an urgent care need through NHS 111 to be able to access to network system of integrated care services where organisations collaborate to deliver high quality, clinical assessment, advice and treatment. Patients requiring urgent help will access this through their GP. However, when their practice is closed, NHS 111 will be the primary route to urgent care services. Central to this approach will be the development of 'clinical assessment and treatment' (CAATS) services across North West London offering patients who require it access to a range of clinicians, both experience generalists and specialists. The Clinical Assessment, Advice and Treatment Service will provide support directly to patients who access North West London NHS 111 by receiving appropriate calls directly from NHS 111 call handlers, health advisers and clinicians. The service will also be accessible by health professionals in the community and within the acute sector (if required) so that no decision needs to be taken in isolation. Vision To align and reduce duplication of unscheduled care services in order to improve accessibility and the patient experience. To manage patients effectively, reducing unnecessary steps To ensure that access to services is coordinated in order to avoid the need for patients to navigate a complex and confusing system For all services to be technically linked to an IT infrastructure that facilitates the sharing of patient records, referrals and booking of appointments as part of an integrated system. To create an integrated unscheduled care service that is coordinated between Primary, Planned, Urgent, Intermediate, Mental Health, Social Care, Community and Paediatric care services and other parts of the healthcare system. A plan for online provision in the future will make it easier for the public to access urgent health advice and care. This will increasingly be in a way that offers a personalised and convenient service that is responsive to people s health care needs when: They need medical help fast, but it is not a 999 emergency. They do not know whom to contact for medical help. They think they need to go to A&E or another NHS urgent care service. They need to make an appointment with an urgent care service. They require health information or reassurance about how to care for themselves or what to do next. Figure 1. Diagrammatic representation of a functionally integrated urgent care service: 2

3 National Context The NHS Five Year Forward View (5YFV) explains the health services in England for people of all ages with physical and mental health problems, and sets out the new models of care needed to do so. The 5YFV highlights that the traditional divide between primary care, community services, and hospitals is increasingly a barrier to the personalised and coordinated health services required for patients. The management of long-term conditions is now a central task for the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected episodes of care. The FYFV sets out a clear programme of change to better connect care across organisational boundaries for these patients, including; Delivering care through a system approach using networks of care not just single organisations Increasing the focus on out-of-hospital care Integrating service around the patient, including ensure health, mental health and social care services are co-ordinated Continually evaluate new models of care and develop them to provide the best experience for patients and best value for money Integrated urgent care services are fundamental to deliver this programme of change and provider(s) will deliver against the objectives set out above whilst continually working alongside partners to evolve the model in accordance with the strategic direction of NHS NWL CCGs and our Local Authority Partners. Local Context Shaping a Healthier Future 3

4 Shaping a Healthier Future (SaHF) is a clinically led programme being delivered across the eight Clinical Commissioning Groups (CCGs) in North West London (NWL) which will create a future healthcare system in NWL to meet the changing demands of the population, improve standards, and provide a sustainable financial future. The vision for care in NWL is underpinned by four overarching principles detailed below: Personalised Enabling people to manage their own care themselves and to offer the best treatment to them. This ensures care is unique. Localised Localising services where possible, allowing for a wider variety of services closer to home. This ensures care is convenient. Integrated Delivering care that considers all the aspects of a person s health and is coordinated across all the services involved. This ensures care is efficient. Specialised Centralising services where necessary for specific conditions ensuring greater access to specialist support. This ensures care is better. Delivery of SaHF is directly supported by the North West London Five Year Strategy and a series of transformation programmes have been initiated to deliver SaHF. All of these programmes are relevant to the delivery of the Integrated Urgent Care Service. These transformation programmes are: Primary Care Transformation (including out-of-hospital): Placing Primary Care at the heart of whole system working, and improving access to GP services. Whole Systems Integrated Care: Coordinating care across commissioning bodies and providers, centred on the patient. Acute Reconfiguration: Improving hospitals to deliver better care 7 days a week, and ensuring there are more services available closer to home. Mental Health Transformation: Improving mental and physical health through integrated services. North West London Five Year Strategy The eight North West London CCGs have developed and agreed a five-year strategic plan, which outlines five strategic objectives. These are: Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Ensuring that people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm. 4

5 Primary Care Transformation Primary care in North West London is seeing unprecedented levels of change in terms of transformation of primary care service delivery. Practices are delivering a suite of new Out of Hospital Services, requiring implementation of new systems and processes and training and development of staff to ensure required competencies can be delivered. In addition across the CCGs there is an ambitious programme for new models of primary care for different patient groups (i.e. whole systems) with the aim of ensuring seamless coordinated care across the primary care landscape for patients with more complex needs or vulnerabilities. The provider will be expected to respond to and support the focus of this transformation programme, working with practices to ensure the needs of the patient population are met through co-design and mutual alignment. Whole Systems NWL is one of 14 pioneer sites to implement integrated care at scale and pace. Across the 8 boroughs, 31 partner organisations have agreed to work together in pursuit of a shared person-centered vision for integrated care. While all boroughs are developing their own approach to whole-systems, the principles, which underpin these approaches, are shared. Accountable Care Partnership/s Across North West London CCGs are actively working together in collaboration with providers to consider what Accountable Care Partnership/s (ACP) could look like across our local health and social care economy with implementation by April Integrated urgent care service providers will be expected to work with providers from across the system, particularly intermediate care providers and urgent care services, to contribute towards the development of an ACP. Like Minded Mental Health Transformation Programme The Collaboration of NWL CCGs and system leaders across North West London endorsed the commencement of a programme to develop a NWL-wide Whole System Mental Health & Wellbeing Strategic Plan. This builds upon the previous NWL Mental Health Strategy (Shaping Healthier Lives) and the Whole Systems approach to involving health and social partners as well as service users and the voluntary sector. The first phase of the Like Minded programme focused on the development of a Case for Change, which describes the eight major issues identified across North West London relating to mental health and wellbeing, and the ambitions to improve outcomes and experiences. The Case for Change is built on a wide range of data, people s experiences, best practice and a structured approach to prioritisation, to agree a number of shared priority work streams. It has been endorsed by Health & Wellbeing Boards, CCG Governing Bodies, Central and North West London Mental Health Trust and West London Mental Health Trust. Commissioners would be looking to work actively with providers to deliver this vision. The provider(s) of the Integrated Urgent Care Service would be a key component of this vision and would be expected to work with other providers to work towards a single 24/7 clinical Single Point of Access for reactive care management 5

6 which would act as the focal point for the tri-borough intermediate care service and also the Clinical Assessment and Treatment Service for the three boroughs. 2. Outcomes o NHS Outcomes Framework Domains and Indicators Domain 1 OUTCOME 1 OUTCOME 2 Domain 2 OUTCOME 3 Domain 3 OUTCOME 4 Domain 4 OUTCOME 5 OUTCOME 6 OUTCOME 7 Preventing people from dying prematurely People are assessed, provided with advice and/or treatment and discharged from the service within the specified timeframe by appropriately skilled and qualified staff leading to an appropriate clinical outcome People who ring NHS 111 have access to the right care, in the right place, by those with the right skills, the first time. Enhancing quality of life for people with longterm conditions People with long-term conditions are treated in-line with their care records and wishes and are provided with the most appropriate treatment for their needs first time. Helping people to recover from episodes of illhealth or following injury People who ring NHS 111 receive a holistic and personalized service which responds to their immediate need in a timely fashion and also arranges for any follow-up care and support required within a single episode of care Ensuring people have a positive experience of care People have access to a service 24/7 which supports them in effectively navigating the urgent and emergency care system People s perceived urgent care need is dealt with in a personalized way that takes into account their holistic need People are provided with information and options for self-care and are supported to manage an acute or long-term physical or mental condition X X X X 6

7 OUTCOME 8 Domain 5 OUTCOME 9 People received improved patient care, experience and outcome by ensuring the early input of the most appropriate senior clinician when required. Treating and caring for people in safe environment and protecting them from avoidable harm The service is accessible and provides the same quality of care to all patients who access the service. X OUTCOME 10 o People who use the service have their care needs responded to within a single episode of care which minimizes the need for handovers and re-triaging between services. Local defined outcomes In addition to the outcomes specified above, the service is also expected to deliver the following outcomes: The efficiency and productivity of the urgent care system is increased with a reduction in the overlap and duplication across service provision and clinical time. Public access to urgent healthcare services appropriate to their needs is improved on a 24/7 basis Patient and/or their family/carers are provided with information and options for self-care are supported to manage acute or long-term physical and mental conditions If an onward referral is required, patients experience this seamlessly e.g. through direct booking of appointments at a wider range of urgent or unscheduled care services. public satisfaction and confidence in the NHS, and particularly 111, is increased The quality and experience of patient care is measured and acted upon to ensure continuing service improvement 3. Scope 3.1 Aims and objectives of service The following core principles reflect the ambition for the Integrated Urgent Care Service. As the service evolves these core principles are likely to develop further. People contacting NHS 111 for urgent care needs expect the service to: Be always available, 24 hours a day, 365 days a year Be accessible, personalised and based on their individual needs 7

8 Have knowledge of when they have previously contacted NHS 111 so they do not need to repeat their story Be able to connect them to a clinician with access to important health records and notes Be safe and give the right advice based on the best and most up to date clinical and medical knowledge available Definitively resolve health concerns without the need to go anywhere else if appropriate Book appointments with the urgent care provider they need To dispatch an ambulance without delay if necessary Be able to access the service through digital or online channels both to give better access to information and to meet specific needs people have Make sure that specific health needs, such as palliative care, mental health and long term conditions are properly catered for. NHS 111 should provide a consistently high quality service irrespective of the geographic area. 3.2 Service Delivery Vision The core vision is to deliver and continuously develop a high quality 111 and out of hours services which operates as part of a locally defined integrated Urgent care system which streamlines access for patients by offering a single entry point through NHS 111 and a fully integrated pathway for patients through the urgent and unscheduled care system 3.3 Service description/care pathway To deliver the integrated urgent care system, we are looking for provider(s) to deliver: A North West London NHS 111 Telephony and Digital Service; and Two Clinical Assessment and Treatment Services (CATS) which will be integrated within NWL NHS 111 and will operate across the following geographies: o Brent, Harrow and Hillingdon CCGs o Central, West, Hammersmith and Fulham, Hounslow and Ealing CCGs. The NHS111 will provide a single entry point for patients who: may need medical help fast, but it s not a 999 emergency don t know who to contact for medical help think they you need to go to A&E or another NHS urgent care service require health information or reassurance about what to do next. Clinical Assessment, Advice and treatment Services (CAATS). NHS 111 will be integrated with the two Clinical Assessment and Treatment Services (CAATS). The two CAATS will provide patients who require it access to a range of clinicians, both experienced generalists and specialists for assessment and treatment. The service will also be accessible by health professionals in the community and within the acute sector (if required) so that no decision needs to be taken in isolation. 8

9 The core components of the CATSs will include: A core GP and nurse-led service who will assess, provide advice, provide telephone treatment or book onwards treatment for patients calling NHS 111 on an Out of Hours basis; and The development and integration into NHS 111, of a virtual network of established urgent care services which already offer clinical assessment and treatment services. Proposed pathway Patient rings 111 or online contact Non-clinical call handler follows algorithm and assesses whether patient can just be given advice or needs to speak to a clinician Algorithm shows patient doesn t need to go through to CATS Patient given health advice by call handler or told where to go e.g. a pharmacy or to contact own GP Algorithm shows patient needs to go through to CATS for clinical assessment (e.g. older people, paeds etc) Patient put through to CATS and speaks to appropriate clinician (GP, nurse, paramedic, mental health worker, social worker, pharmacist or dentist) Patient given clinical advice or booked into a service directly Patient booked into appropriate service: 1. GP appointment 2. UCC appointment 3. Dentist appointment 4. Appointment in a community service 5. E.D. or ambulance 6. Referred to pharmacy 7. Referred to social care 8. Referred to mental health SPA 9. Home visit booked Clinical Advice (or Clinical Hub ) 9

10 The composition of the CAATs will be confirmed once the business case has been finalised, but is likely to include the following professionals: Specialist or advanced paramedics with primary care and telephone triage competences; Nurses with primary, community, paediatric training and/or urgent care experience; Prescribing pharmacists; and GPs with enhanced telephone assessment skills. The Provider shall adapt the staffing of the Clinical Hub in accordance with local needs. This may also include social workers if the need is identified during the lifetime of the contract. Wherever possible individuals working in the clinical hub will be based in that community, and must be able to liaise with local physical and mental health services and social care. Dental Advice Dental pain without injury remains one of the highest reasons for calling NHS 111. NHS England is responsible for commissioning all NHS dental services and CCGs will work with NHS England to ensure that dental services are made available to the Provider in the area covered by the Integrated Urgent Care Service. The dental case mix needs to be managed by suitably trained dental professionals, which may include dental nurses trained in triage. Where possible callers may be booked into treatment slots directly with dental treatment providers. Clinical Advisers shall be able to refer and receive cases from dental services. In addition, Interactive Voice Response (IVR) shall be used, where possible, to improve the patient experience. Management and referral of callers with dental symptoms: The Provider will need to manage callers with dental symptoms using a clinical decision support system in use for the overall service. During the in-hours period, Monday to Friday 08:00 to 18:00, these callers will be referred to services returning from the DoS. Between the night time hours of 1800 in the evening until 0800 the following morning, calls will be handled by the Provider and directed through the DoS and sent to the Dental Assessment Service via the Interoperability Tool Kit (ITK) including an encounter report. Callers who are not physically within their home area Boroughs at the time of their call will be managed through the CDSS and the DoS at all times. The provider must ensure that clinical Advisers receive suitable training on the management of callers with dental symptoms in order to appropriately refer or manage cases that cannot be referred to another service. The Provider shall provide a call log extract in relation to dental cases. Where a caller with dental symptoms is identified as a frequent caller the Provider will need to have processes in place to identify these cases and manage them outside of the CDSS through a clinical Adviser. 10

11 The Provider shall ensure that all clinical advisers have received training on Toxbase or its equivalent to ensure that analgesia overdose can be identified and managed amongst these callers. The Provider shall ensure that all staff are trained in dental trauma identification and management. The Provider shall make contact with the Dental Assessment Service via a telephone by-pass number where indicated. Mental Health The Provider shall ensure: The Integrated Urgent Care Service is staffed by competent Health Advisers who have received mental health training as agreed with the Commissioner, and who are supervised and supported by qualified Clinicians. Caller feedback to be obtained and reported on to ensure that Patient experience in this area is improving; Clinicians within the Integrated Urgent Care Service shall have access to relevant aspects of patients mental health crisis record; and Networks of support and service user defined recovery outcomes shall be included, be reviewed regularly and kept up to date, particularly following any crisis presentation, admission or significant change in an individual s circumstances. They will also identify factors which have the potential to precipitate a crisis and what steps can be taken to reduce the likelihood of a crisis in such circumstances. The Provider shall be aware and work to the principles of the Mental Health Crisis Care Concordat Improving Outcomes for People Experiencing Mental Health Crisis (18 February 2014) 6and work with Commissioners and patient groups to ensure the most convenient and appropriate access to mental health services. In accordance with the Mental Health Crisis Care Concordant, the Provider will work with local mental health services to ensure early identification of appropriate callers and timely onward referral to local mental health crisis services. The Provider shall ensure Health Advisers manage Patients in line with local mental crisis plans when they are available. The Provider shall work in partnership with mental health services to; Access crisis plans; Agree referral protocols for mental health patients in crisis; and Complete end to end patient pathway reviews to ensure patient pathways continue to improve Pharmacists in the clinical hub The Provider shall ensure that advice from the Service pharmacist shall include: Medicines enquiries; Health information enquiries; Requests for urgent repeat medication; Medicines advice for minor illness; Poisons and accidental overdoses; 11

12 Contraception advice; and Any other advice that a registered pharmacist with training is able to provide. This specification sets out more detail on these core components of the new Integrated Urgent Care Service 3.4 COMPONENT 1: North West London NHS 111 Telephony and Digital Service The NWL NHS 111 Telephony and Digital Service ( NHS 111 ) will deliver integrated access at the heart of the Integrated Urgent Care Service working with the CATSs to extend new pathways across health, social care and voluntary sector (Primary Care, Community, Urgent and Emergency services, Acute, Social Care, Voluntary sectors) through the NHS111 service 24/7, 365 days a year Access The NHS 111 service will: Accept all calls from the public via any agreed channels including telephone and digital channels. Accept all calls from Heath Care Professionals (HCP) calling for clinical advice. HCP calls may be received from: o Ambulance Services o Urgent and Emergency Care Services o Community Services o Social Care professionals o Primary Care o Other 111 services o Community specialist services o Learning Disabilities services Front end telephone message NWL NHS 111 should have the ability to provide front end telephone messages (IVR options) to give patients the option to be directed to other clinical professionals/services prior to their call being answered by NHS 111 Health Advisor. These options will be agreed with Commissioners and will reflect arrangements already in place. During the OOH period, their already exist a London wide IVR arrangements in place to manage: Dental enquiries Pharmacy enquiries, including repeat prescriptions Call Handling All calls will be answered by Health Advisors (HA) and or Clinicians who are appropriately trained competent and have been assessed as possessing the aptitude, necessary skills and knowledge to undertake their duties as specified and outlined by their individual roles and responsibilities. There must follow safe clear approved policies and protocols which ensure that patients receive the most appropriate support and service first time Calls in other languages 12

13 The service must have access to a translation service 24/7/365 to translate calls made in other languages. Health Advisors need to know how to organize a translator without delay and ensure a translator is available within 15 minutes Calls from people with hearing impairments The service will be able to deliver a good quality service and adapt its model to include patients with hearing impairments. Health Advisors need to be trained to understand how to handle calls of this manner and these calls should be tagged following the patient s first call if this is consented to so that the service can review these calls and improve the response for these patients in the future Pathways The Integrated Urgent Care Service has been designed to ensure that patients receive the most appropriate support and service first time and to reduce handovers and additional triaging of patients where possible. To support this objective, detailed patient pathways have been developed across North West London to ensure that patients demonstrating certain characteristics are treated in a particular way. The agreed North West London pathways are described briefly below and are detailed in diagrammatical form in Appendix Patient Groups New Pathway during OOH period Pathway during in-hours period Under 2s Under 5s Health Advisors rule out life threatening and offer the patient phone consultation or face to face appointment Under 16s,5s,2s,1s CMC/ End of Life Patients Under 16s Health Advisors follows pathways and at the end other triage the patient will be offered the option of a face to face or phone consultation if required from the CATS clinicians Telephony System recognises telephone number and looks for a palliative Care specialised or clinical resource availability in the hub. Where clinician is not directly available, the Health Advisor takes the patients details and transfers the patient through to local palliative care team or into the hub clinical queue for priority 1 call back. Where Pathways identifies life threatening, the Health Advisor will immediately ask for clinical review of notes to identify appropriateness Health Advisors rule out life threatening and offer the patient phone consultation with clinician or face to face appointment Under 5 to 16s Follow normal pathway route. Telephony System recognises telephone number identifies to the Health Advisor the patient has an end of life plan and the health advisor completes module O The Health Advisor transfers the patient through to the local palliative care team or into the hub clinical queue for priority 1 call back. Where Pathways identifies life threatening, the Health Advisor will immediately ask for clinical 13

14 Patients with Management / Crisis Plans Nursing and Residential Homes Complex Patients Mental Health Patients of disposition and management plan before dispatching an ambulance within 30 seconds. Health Advisors rule out life threatening and warm transfer patient to clinical hub. review of notes to identify appropriateness of disposition and management plan before dispatching an ambulance within 30 seconds. Health Advisor rules out life threatening and transfer to pathways clinician to utilise note and manage appropriate onward referral Pathways triage via health advisor and where required pathways clinician, utilising the DoS for onward referral Health Advisor identifies patient is a complex call and early exits with a direct transfer to the urgent care hub For non-medical requests for patients on the mental health case load or new presentations that are non-medical or result in a mental health disposition, the patient is transferred from 111 to the mental health SPA for the CCG. Frequent callers to be reviewed as a minimum monthly and Patient Notes will be developed on appropriate patient management pathway including direct discussions with GP practice that may include direct referral to Pathways clinician, clinical hub or urgent referral to patient own GP practice. Health Advisor identifies patient is a complex call and early exits with a direct transfer to the Pathways clinician For non-medical requests for patients on the mental health case load or new presentations that are non-medical or result in a mental health disposition, the patient is transferred from 111 to the mental health SPA for the CCG. Frequent callers to be reviewed as a minimum monthly and Patient Notes will be developed on appropriate patient management pathway including direct discussions with GP practice that may include direct referral to Pathways clinician, clinical hub or urgent referral to patient own GP practice. Frequent Callers Health Care Advice Non-urgent dispositions (speak to a clinician in 2 hours) Patients that call 3 times in 96 hours are directly transferred to the clinical hub if the outcome is not to send an ambulance to ED, then the call must result in a Speak to GP within 1 hour disposition and the GP must be alerted to the fact that this is the third time in 96 hours that the caller has made contact with the Integrated Urgent Care Service and they should therefore complete a thorough re-assessment of the patient s needs. NHS Pathways Health Advisor and Pathways Nurse NHS Pathways clinician Patients that call 3 times in 96 hours are directly advised to contact their GP surgery and the GP should be sent details of all 3 calls. NHS Pathways clinician Direct transfer to clinical hub Direct transfer to NHS Over 75s Pathways clinician Dental Calls The patient will be managed The service will identify if the 14

15 Repeat Prescriptions Medication enquires Out of London calls Patients from within London through Pathways and the DoS will be used to identify the most appropriate local service Through Pathways and referral to local service Early exit for call back from pathways clinicians Pathways triage via health advisor and where required pathways clinician, utilising the DoS for onward referral Pathways triage via health advisor and where required pathways clinician, following the DoS for onward referral and utilisation of patient s records that are shared through the Pan-London PRM that may provide further referral information. Systems must have the capability to transfer patients to other NHS111 providers and local clinical hubs. patient is calling for dental and use Pan-London agreed dental questions and transfer the patient to the Pan-London dental service. Early exit and referral to PURM via ITK message Early exit and referral to PURM via ITK message The service will support the development of a single Health Advice note to support the health advisor refer the patient to the correct referral pathway as set out above. NWL patients dialing Out of Areas NHS 111 In some cases, NWL patients will access NHS 111 from an Out of Areas position, particularly in boroughs which border other health economies. The provider(s) of the Integrated Urgent Care Service will be required to work with other similar providers across London and England to ensure that where applicable, patients ringing through to these other NHS 111 numbers are transferred to the CATS in-line with the pathways above. Commissioners will support providers to develop the necessary pathways. Reviews Review systems should be a core quality requirement of the service. Critical reviews should form an integral part of all aspects of the services operations and delivery. The Provider should demonstrate how learning from call reviews, audits, serious incident reports, complaints commendations and feedback is incorporated into service delivery and development. WORKFORCE SECTION Assessment of Symptomatic Calls The NWL NHS 111 component will use an approved Clinical Decision Support System (CDSS) to assess and triage symptoms. This system will be used by appropriately trained and competent Health Advisers and/or pathways clinicians to assess the needs of callers. 15

16 The process of clinical assessment shall follow a defined format as recommended by the CDSS provider except where local pathways (including those developed in the section above) have been developed and agreed by the local clinical group. The Provider shall ensure that they adhere to any licensing conditions that apply to the CDSS system including upgrades and training within the time period specified and must support Commissioners in the testing of changes to Directory of Service profiling. The Provider shall ensure that the clinical assessment system is embedded within this patient management system and licensed for use in this way from the appropriate licensing agency. The Provider shall ensure that all calls to the Service are recorded. All data that is stored in this system shall be capable of being extracted for reporting and review purposes. The reason for the call, the nature of any injury or illness and the outcome of the assessment shall be recorded and be clearly identifiable for reporting and review purposes. The outcome shall include the recommendation of both the level of care required and the timescale in which the patient needs to be seen. The CDSS will support the identification of calls requiring transfer to a Clinician within NHS111 and the CATS service and shall include as a minimum: Clearly identifying where a Patient is aged 5 years and under; Clearly identifying where a Patient is aged 79 years and over; Green ambulance dispositions; Validation of home management / self-care advice; Complex cases multiple co-morbidities, no clear symptoms; Multiple symptoms; Patients with clinical care plans / special patient notes; Patients on CMC or similar End of Life Care Register; Repeat and frequent callers; Patients that have asked to speak with a clinician; Healthcare professionals that require clinical advice; Patients that have been assessed and identified as requiring clinical advice; and Refused dispositions Prioritisation of calls transferred to a clinician Description Pathways description Narrative Proposed KPI for call back threshold DX32, DX106, DX321, DX322, DX325 & DX327. These dispositions fall into the criteria of requiring an immediate call back and should be warm transferred to a Clinical Adviser whenever possible. These dispositions are reached following the Health Adviser early exiting the triage because the caller/patient has refused to accept an ambulance Patients not warm transferred must be called back within 10 minutes Warm transferred First attempt to call back within 10 minutes Contract threshold proposal 95% 16

17 DX323, DX324 & DX326 DX34 Dx35 Dx38 response or advice to attend an emergency department within 1 or 4 hours or is reported as having a Toxic Ingestion/Inhalation or a chemical eye splash These dispositions are reached when the caller/patient has refused to accept a disposition which refers them to an alternative health care professional, e.g. the GP or Walk-in Centre or is a frequent caller. Speak to a Clinical Adviser within 30 minutes less urgent than needing an immediate call back but may still require urgent clinical intervention. Speak to a Clinical Adviser within 2 hours these calls should be less urgent in nature as all urgent causes of symptom/problem should have been ruled out during triage. Speak to a Clinical Adviser for home management advice these calls are prioritised without a specific time frame but are not a high priority. Maintain as 100% warm Patients not warm transferred must be called back within 10 minutes The option to warm transfer is available together with the option to place the call in the stack for call back The option to warm transfer is available together with the option to place the call in the stack for call back at peak times to ensure appropriate clinical dispositions are warm transferred The option to warm transfer is available together with the option to place the call in the stack for call back at peak times to ensure appropriate clinical dispositions are warm transferred Warm transferred First attempt to call back within 10 minutes 20 min First attempt to call back within 20 minutes 30 min First attempt to call back within 30 minutes 60 min First attempt to call back within 60 minutes 95% 95% 99% 99% 95% Life threatening conditions If the call is symptomatic (i.e. about an illness or injury) the first step of the assessment is to establish that the patient is breathing, conscious and not bleeding 17

18 heavily, nor experiencing a life threatening condition. If this cannot be established, an immediate ambulance dispatch request is sent automatically to the ambulance service, after which the advisor will provider interim first aid advice until the ambulance arrives Clinical Enhancement for 999 and ED dispositions If NHS Pathways is the CDDS used for the service, clinical enhancement must be implemented for green ambulance dispositions All emergency ambulance treatment and transport dispositions (green dispositions) and Emergency Department dispositions generated by Health Advisors will be referred to a pathways clinician before the ambulance is dispatched or the patient is sent to ED. The clinician will then undertake further evaluation of the patient s condition. If following this further evaluation, it is established that a patient faces an emergency situation, or a requirement for transport that can only be provided by an ambulance service, then an electronic message must be sent to the dispatch queue of the local ambulance service to trigger dispatch of a vehicle to the recorded address within the required timeframe. The message will include the appropriate information required by the ambulance service to determine its priority as, for example, a red or green category response. Where an ambulance dispatch is triggered, the clock-start for the purpose of ambulance national performance targets is defined as the point when the request hits the ambulance service dispatch queue. Every call managed through this process must be documented to provide an audit train and enable a review of the effectiveness of the clinical enhancement Unresolved calls There may be times when a call cannot be resolved by the initial Health Advisor and a pathways clinician is required to complete the clinical assessment. In these cases the call must be warm transferred from the Health Advisor to a pathways clinician, i.e. the Health advisor speaks to the pathways clinician before transferring the call Caller not located with the patient Where a caller is calling on behalf of someone else and they are not physically located with that person, the clinical assessment system will need to include a facility to exit the assessment early and if necessary, escalate the call to a pathways clinician. The advisors should always ask to speak to the patient where possible, but if this is not practical the call should be handled through a third party Caller identified as self-care Where the patient is identified as requiring home management advice to enable symptoms to be managed at home, the Health Advisor will always refer the caller to a Clinician via a warm transfer. In appropriate circumstances, where a Clinician is not available, a call-back should be made within 60 minutes. 18

19 The clinician (who must be a health professional) will be able to review and validate the assessment carried out by the health advisor. Assuming the situation has not changed, and the clinician agrees with the outcome, the clinician will use the CDDS to deliver evidence based care advice to enable the patient's symptoms to be managed at home Non-symptomatic calls A person may call NHS 111 for health information and advice; this should be provided by a health advisor using the CDDS and Directory of Services without the need for another call or onward referral Post Event Messages (PEMs) PEMs structure and system requirements must as a minimum meet the requirements set out in the lasted version of the NHS111 Interoperability toolkit and be upgraded as required including the ability to suppress PEMs where required agreed. Every answer given by a caller during assessment must be recorded and form a summary of the assessment available to pass on to the CATS or to an NHS service to which the patient is referred to. This should include details of the disposition reached, and the timeframe for care delivery to ensure that the receiving service can priorities the patient appropriately. At the end of every call, regardless of the outcome, the advisor must be prompted by the CDDS to provide the caller with specific evidence based advice on what to do if symptoms worsen, and guidance on particular issues to look out for which may indicate the development of a more serious condition. All calls must end with advice to call back if anything changes. The caller may also be signposted as appropriate to local services in their locality, e.g. diabetes support groups, asthma society which could help to support and encourage further self-care and self-management. Referrals made to other services from face-to-face consultations shall include electronic transfer of data with the appropriate information as part of the agreed referral protocol to ensure Patients do not have to repeat themselves other than to validate who they are or detail any symptom changes. In areas where agreement for direct referral to other services (acute, community, mental health, sexual health, social care, own GP, etc.), the Provider s electronic system will contain details about the referral process for each service and where possible the face-to-face consultation assessment information will be sent to the selected service electronically. In all cases, the Provider shall make it clear to the User about which service they are being referred to, what the next steps in their care pathway are and within what timescale their next contact will be. Where Patients are expected to attend or contact the service they are being referred to themselves, the Provider shall provide the relevant contact details directly to the Patient. Where it is possible the Provider will book directly into a service. Where a referral is not made through a direct appointment, detailed arrangements for the referral process must be put in place and agreed by the clinical governance lead. The full referral process shall be visible to Commissioners, including alternative manual process. 19

20 3.5 Component 2: Clinical Assessment and Treatment Services The NWL Integrated Urgent Care Service will make use of two Clinical Assessment and Treatment Services (CAATS) made up of experienced generalist and specialist clinicians which will work in an integrated way with NHS 111 to provide urgent care assessment and treatment to patients. In particular, the CATs will provide an integrated response to: people who receive a 'speak to' or 'contact' primary care disposition from NHS 111 during the Out of Hours period. People who have more complex conditions or need their health to be managed in line with an agreed care plan; People who may benefit from the support of specialist clinicians. People at risk of an emergency hospital admission who may be suitable for urgent reactive care in the home or community. The CATS will consist of: An enhanced core out of hours assessment and treatment service managed by experienced generalist clinicians with additional specialist clinical support as required. An integrated virtual network of established urgent or unscheduled care services which already offer clinical assessment and treatment services. The provider(s) of the CATS will take responsibility for working with providers of these services to integrate their operations into the CATS and NHS 111 through the use of standard operating procedures, the integration of telephony services and IT systems Operational Management across CATS and out of hospital community services The vision for the Integrated Urgent Care Service is that the provider(s) of the CATS will oversee the operational management and coordination of resources across providers who deliver triaging and home visiting services across the CCG areas, working with those providers to maximize the efficiency of the resources, by virtually working as one service Hour of operation The CATS will provide an enhanced core telephone triage service during the out of hours period defined as hours until hours on weekdays and the whole of weekends, bank and public holidays. Access to the Service must therefore be available to patients from hours on the last normal working day until hours on the next normal working day in any period. However, the CATS will also be responsible for bringing together a range of telephone assessment and triage services from across the CCG areas which operate across a 24/7 period. 3.6 Access The CATS will be required to receive calls via the following routes: 20

21 From a health advisor or clinician in NHS 111 where a relevant disposition has been reached for a patient following a full pathways assessments For some patients (as set out in the pathways within section x) some calls will be directly routed from NHS 111 to the CATS following lifethreatening assessment, but without completing a full pathways assessment Direct referrals from online or telephone app triage where a relevant disposition has been reached. An online channel for the integrated urgent care service is under development and expected to begin in Some dispositions will be sent directly from the online channel to the CAT Direct calls from local health professionals who require advice from a generalist or specialist clinician including community services, paramedics and social care professionals Call Handling and handover from NHS 111 In most cases, initial call handling and clinical triage will be undertaken by NHS 111 and the call will be 'warm transferred' from a health advisor or clinician within NHS 111 following a full pathways assessment. A robust system will be put in place to manage the transfer of information from the NHS 111 service. All calls requiring Out of Hours primary care contact should be 'warm transferred' from the health advisor or clinician within NHS 111 to a senior clinician within the CATS, ideally this should be an experienced local GP or Advanced Nurse Practitioner. If a 'warm transfer' is not possible, a senior clinician should contact the patient or carer by telephone, within a required timeframe. This should be measured from the time at which NHS 111 receives the initial call. A definitive clinical assessment that will enable the advising or treating clinician to develop an appropriate management plan in conjunction with patient should be undertaken. Clinicians undertaking telephone assessment must work within a clearly defined operating model, which reflects the different elements of the process within the integrated urgent care service. Specifically this includes: Handover from Advisor to Clinician, or Pathways Clinician to Clinician this must be structured and discussions must take place on recorded telephone lines Validation by Clinician of any previous assessment Structured clinical telephone assessment with or without the aid of CDSS Some calls will be streamed direct to clinicians in the CATS (e.g. through Direct call routing, or calls received from a health professional) without assessment by a Health Advisor or pathways clinician. These calls must be managed in a similarly structured way. The patient or carer should receive telephone advice and treatment. Where this is not possible they should be seen by the most appropriate clinician in the most appropriate place i.e. an appointment at their local Urgent Care Centre or be designated for a visit at the patients' location Telephone clinical assessment in CATs 21

22 Patients managed with the CATs service must be triaged using recognised and appropriate Patient management systems within their service to ensure the accurate and safe assessment of patients and recording and retrieval of all relevant information. In addition, the Provider of the service must ensure that they adhere to any licensing conditions that apply to using their system of choice. This must include the ability to link with the wider urgent and emergency care system. National Quality Requirements in the Delivery of Out-of-Hours Services (Gateway no. 6893) [DH, 2006]. Set out in Appendix 2 identify the requirements of clinical assessment. Providers must have a robust system for identifying all immediate life threatening conditions and once identified, those calls must be passed to the ambulance service within three minutes. Providers that can demonstrate they have a clinically safe and effective system for prioritising calls, must meet the following standards: Start definitive clinical assessment for urgent calls within 20 minutes of the call being answered by a person. Start definitive clinical assessment for all other calls within 60 minutes of the call being answered by a person. Providers that do not have such a system must start definitive clinical assessment for all calls within 20 minutes of the call being answered by a person Home visiting A face-to-face home visit consultation will be conducted in the patient s place of residence. The place of residence is defined as any address specified at the time of visit (e.g. home, nursing home, hospice, hospital or treatment centre). All face-toface consultations, where conducted, must meet the performance standards outlined in the contract and the National Quality Requirements, including that visits are taken place within the following timescales, after definitive clinical assessment has been completed: Emergency: within 1 hour; Urgent: within 2 hours; and Less urgent: within 4 hours. The Provider(s) must specify the number of vehicles, type of vehicle and equipment to be used. Vehicles and equipment should not be used for any other purpose other than those services outlined in this specification and under this contract. Home visits will be made by an appropriately skilled clinician, using a suitably equipped vehicle. The clinician will either treat in-situ or, where required, send the patient to an appropriate service for on-going treatment and use the mobile DoS The provider(s) will agree with commissioners the clinical and non-clinical protocols, with clear reasons and criteria that indicate when a home visit is considered appropriate. This criteria needs to include the mode of transport for staff including: the number of vehicles needed, the bases, drivers and associated assurances. All protocols will have version control and a demonstrable mechanism to show that regular review is undertaken, with upgrading as required. 22