Commissioning for Value:

Transcription

1 Cmmissining fr Value: Reducing the Number f High Intensity Users f Unscheduled Services Dr. Mark Jhnstn Deputy Chief Operating Officer Rhian Mnteith Advanced Paramedic February 2015 Right Care Casebk Series

2 The setting NHS Blackpl CCG and NHS Fylde & Wyre CCG The situatin r prblem NHS Blackpl CCG and NHS Fylde &Wyre CCG are bth lcated n the Nrth West cast f England and jintly have a registered ppulatin f sme 320,000 living in a mix f castal twn and rural villages. Prvisin f high quality and apprpriate health and scial care t the Fylde Cast ppulatin is challenging, as it is an ageing ppulatin, with a higher than average burden f lng term cnditins and evidence f c-mrbidities. There are als areas f extreme deprivatin acrss the Fylde Cast with lwer than average earnings and pr husing tgether with high levels f unemplyment. In additin, the area attracts peple with risk-taking behaviurs and chatic lifestyles which als present a challenge fr the prvisin f healthcare. Life expectancy in sme areas is markedly belw the natinal and Nrth West average. The tw CCGs wrk in partnership n a number f initiatives t imprve health utcmes fr their respective ppulatins. Blackpl and Fylde & Wyre CCGs spent a ttal f apprximately 86 millin n unscheduled care services in 2011/12, and demand was predicted t increase. What actin was taken? NHS Blackpl & NHS Fylde and Wyre CCG used the NHS Right Care apprach t supprt strategic planning and infrm delivery f prgrammes that will enhance its cmmissining apprach, making it sundly based n evidence and with a clear emphasis n utcmes. They used the three-stage Right Care methdlgy (Where t lk, What t change, Hw t change) t fcus n clinical prgrammes and identify value pprtunities, as ppsed t fcusing n rganisatinal r management structures and bundaries. 1. Where t Lk Several surces infrmed the decisin making prcess. The CCG used the tls develped by NHS Right Care, including Cmmissining fr Value packs. They als used cmparatr tls, including the NHS Atlases f Variatin, Outcme Packs (CCG and lcal authrity versins) and Anytwn mdels. The Staffrdshire and Lancashire Cmmissining Supprt Unit (CSU) carried ut a diagnstic fr Lancashire CCGs, which crss-referenced all f the main data surces, including: spend and utcmes; Jint Strategic Needs Assessment (JSNA); and lcal health and wellbeing plans. These data were triangulated with the Cmmissining fr Value utputs, with significant crrelatin and therefre assurance f the key areas f pprtunity t priritise. The data analysis undertaken fr NHS Blackpl and Fylde and Wyre CCGs demnstrated that Unscheduled Care was a key area fr imprvement. A substantial prprtin f the healthcare budget was accunted fr by relatively few patients, sme f whm have multiple lng-term cnditins and/r are elderly/frail. System refrm was required t achieve Accident and Emergency targets and t reduce nn-elective admissins t hspital by 15%. Right Care Casebk Series

3 2. What t Change An analysis f the Nrth West Ambulance Service database shwed that the tp 100 frequent callers within the Fylde Cast called 1100 times during a three mnth perid, and it was decided t identify and address the issues f these high intensity users t reduce the burden n unscheduled care services. 3. Hw t Change An initial small pilt demnstrated that an apprach f empathy and caching rather than enfrcement had the ptential t reduce the number f 999 calls. The Urgent Care Bard f Blackpl and Fylde & Wyre CCGs apprved a business case fr the High Intensity Users Prject. An Advanced Paramedic (AP) was appinted t lead this wrk. The principles f the prject were t: 1. Identify. The tp 100 frequent callers were identified utilising the NWAS data systems. Sme additinal patients were selected due t their vulnerability as ppsed t chrnic ambulance calling. This grup may have nly called between 8-10 times ver the previus three mnths but presented with episdes f self-harm r hmelessness. 2. Persnalise. The patients were cntacted directly by a phne call frm the AP. Calls were made t the patients befre the AP spke t prfessinals in rder t avid any bias and at n pint was the frequency f dialling 999, r the reasn(s) fr the calls, mentined t the patient. The calls fcused n the patients issues, identifying and demedicalising their needs. 3. De-escalate. Many high frequency callers ring 999 due t an escalatin in their scial, emtinal, financial r family issues. De-escalatin was facilitated by ffering immediate access t an apprpriate supprt service. Presenting issues may nt be reslved during a crisis cnversatin therefre cntact was made the fllwing day t endrse psitive behaviurs and build trust. 4. Discharge frm the prject t lcal supprt services tk place when the patient required n-ging supprt. One such service is a partnership between Vitaline and the Mental Health Helpline. Vitaline prvided telephne units within the hmes f High Intensity Users wh regularly required supprt ut f hurs. Fr patients experiencing anxiety, depressin, and feelings f self-harm r lneliness, they were able t be cnnected thrugh t the Mental Health Helpline, annymusly and free f charge frm within their hme envirnment. Many patients, fllwing initial supprt frm the High Intensity User Service, were discharged withut the need fr fllw up. 5. Managing relapse. Frequent callers ften start ut n the prject feeling extremely psitive, decrease their dependency and imprve their persnal utcmes. Smetimes, after abut 3-6 mnths, this is fllwed by a relapse which leads t the calls t 999 reccurring. Frequent callers were infrmed f the pssibility f relapse at the utset and, with the supprt f the AP, and pen and hnest cnversatins culd prevent a ptential relapse. Right Care Casebk Series

4 What happened as a result? When the emtinal and scial needs f frequent callers were met, any factitius medical presentatins tended t disappear. By addressing individual human need, unscheduled care cntacts reduced as a by-prduct. The fllwing table demnstrates the impact f the prject in the first fifteen mnths calls A&E Attendances Admissins Self-Harm Incidences 999 calls were dwn by 89% A&E attendances were dwn by 93% Admissins were dwn by 82%. 98% reductin in self-harm incidences 44% reductin in plice calls fr the patient chrt Ttal savings f 2,757,380 have been demnstrated ver the past fifteen mnths, with Blackpl CCG saving 1,333,374 and Fylde & Wyre saving 1,424,006. The pilt cst 70,000 As a result f the CCGs wrk with their partners there has been minimal grwth in nnelective demand in secndary care against a backgrund f natinal grwth in this sectr. Due t the success f the pilt, the aim is t embed the mdel int primary care, by prviding health caching t vulnerable and high health service users wherever they present in the system. Lancashire Cnstabulary have mirrred the techniques used by this prject fr plice High Intensity users. Early results demnstrate similar patterns f reductins in call vlume and 999 respnses. Right Care Casebk Series

5 What was the learning as a result f this experience? The NHS Right Care prcess underpins strategic planning and supprts change An initial pilt study was required t prvide the evidence base essential t gain clinical and managerial buy in Significant resurces can be released Engagement f all stakehlders including the vluntary sectr was required Right Care Resurce Centre Right Care has a new resurce centre where CCGs can find supprting materials describing the Cmmissining fr Value apprach: Online learning vides hw t guides Theme based Webinars Casebks shwing learning frm early adpters Essential reading lists and glssary Tried and tested prcess templates t supprt taking the apprach frward Right Care Casebk Series