Practice Managers Meeting HSE 2011

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					The Roll-Out of Primary
  Care Teams in 2011
   Practice Managers February 19th 2011
  Helen Deely HSE (Regional Specialist in
    Primary Care Dublin Mid-Leinster)
Primary Care
   Health Strategy 2001
   Primary Care Strategy
   Primary Care - 90 – 95% of
    all health and social needs
   Secondary Care – complex
    and special needs
   Central focus of the health
    system
   Team based approach to
    health service provision.
   Shift appropriate activity
    from hospitals
Why develop a Primary Care Team?
                                             Information and Service Flow now
 Information and Service Flow in the past
                                               - Integrated Primary Care Team
      - Non Integrated Local Service


                                                               GP
           PHN                Phy



                                               PHN                           Phy
                      GP

      OT                            SW




                                                     OT                 SW




                 Direct Referral                          Direct Referral and Feedback

                 Referral Service Feedback
Formation of PCT’s guided by the
following requirements:
  To maximise coverage for 100% of population
  To ensure ease of access to services and
   simplify communication and referral processes
  To support epidemiological population health
   monitoring, especially health inequalities
  To facilitate community involvement in need
   assessment
  To support evidence based decision making
  To support future management and
   governance arrangements within HSE.
  To facilitate team working amongst health
   professionals including GPs
Who’s involved in Primary Care?
Establishing the Team
    GP
    Practice                           Reconfigure existing staff:
     nurse                                         PHN
    Practice                                      RGN
     staff
                                              Clerical Admin


                Primary Care Team




                  Additional staff:
                    Physiotherapy
                 Occupational Therapy
                    Social Worker
          Network Services & Linkages

                         Integrated
                          Services
    Hospitals              • Child Protection                    Multi
                                    PCT ‘A’

               • Counselling
                                                               Agencies             Each Primary Care
                                               • Orthodontics
                                                                    • Private
   • Local
                     PCT ‘E’                       PCT ‘B’          Providers
                                                                                    Team is planned to
                                                                                    be part of a wider
 • Area                                                               • Voluntary   network known as the
          • Psychiatry    PCT ‘D’                            • Dietetics
                                              PCT ‘C’
                                                                                    Health & Social Care
• Specialist                                                         • Support
                                                                      Groups        Network.
                • Home
                                                        • Other
                  Help
                               • Alternative
                                    Care
Health & Social Care Network Services
   Audiology Services
   Psychology / Counselling Services
   Podiatry Services
   Community Health Medical Services (Area Medical Officers)
   Community Welfare Services
   Dental Services
   Dietetic Services
   Ophthalmology Services
   Environmental Health Services
   Civil Registration Services
   Community Development Services
   Carers Services
Where we came from?
   Survey undertaken (August 2008) involving GPs and Public
    Health Nurses who were not in Primary Care Teams
    determined that:
      20% of GPs and PHN never had face-to-face contact
      29% of GPs indicated that they did not know the PHNs
       by name
      97% of GPs and 81% of PHNs had no working email
       address for each other
      56% of GPs and 77% of PHNs did not have each others
       mobile phone number
      Although 45% of GPs and PHNs were in weekly phone
       contact, as many 1 in 25 (4%) reported contact on less
       than an annual basis. PCTs provide multidisciplinary
       care, which was previously provided in a unidisciplinary
       manner prior to the establishment of Teams.
Aim of the Primary Care Team
To provide Primary Care Services that are:
 Accessible
    Anyone who lives in the team geographic area
    Service users can self-refer
 High Quality:
    Care planning
    Service planning
    Continuous education
 Meet the needs of the local population
    Liaison with local community
    Needs assessment
    Once off needs & chronic complex needs
What do PCTs do?
   First point of contact

   Defined set of core community-based services

   individual care plans for patients with chronic illness or other
    complex needs.

   Link with other community-based professionals such as mental
    health.

   Integrate with acute hospital services - reduce hospital admissions,
    early discharge of patients and chronic disease management
    programmes.
Clinical Team meetings
   Central to Team functioning
   Feedback from GPs highly positive
   Business like fashion – agendas, list of
    patients etc circulated in advance
   Leadership within Team required – TDOs
    facilitated work to date.
   Acknowledged there is a myriad of contacts
    outside of CTMs.
   Supporting systems required – Admin and
    governance
   Variances apparent – need to identify reasons
    and solutions
CTM Variances
   Of the 246 Teams that held Clinical
    Team meetings held in September:
       71% of Teams held 1 CTM (175              5% 2%
        PCTs)
       21% of Teams held 2 CTMs (52        21%                 1

        PCTs)                                                   2
                                                                3
       5% of Teams held 3 CTMs (13 PCTs)
                                                                4
       2% of Teams held 4 CTMs (6 PCTs)                  72%



   11% PCTs held no CTM in month

   23% had CTMs without GPs
PCT Challenges
   Change from traditional linear working
    to multi-disciplinary
   Different roles & personality
    differences
   Contractual differences
   Leadership issues
   For Teams to work well they must be
    properly resourced – staff, skills,
    training, information, equipments,
    access to specialists etc
Challenges cont…
   CHANGE!! Becoming a team
   Recruitment & non replacement of staff
   Capacity: cradle to grave; health & social
    services
   Boundaries
   Accommodation
   Clinical audit : patient pathways
      Lack of systems to record how much we
       do/how well we do it/ how much it costs us to
       do it
   IT: no single patient record, no secure email
GP Engagement
 Locally through the TDO
 Estates for PPPs
 Primary Care Support Doctors – local &
  national forums
 Exploration of CME Credits for education
  element of CTMs (not agreed).
 Joint initiatives to engage GPs
 Business like approach to Mtgs – prove
  the benefits.
Example of PCT initiatives
  Dietitian Clinic & shared Care diabetes
  Smoking Cessation
  Falls Prevention Groups
  Incredible years
  Antenatal clinics
  Reduction in outpatient appointments
   physio/dietetics clinics, etc.
  Joint discharge planning between acute &
   Primary Care
  Pharmacy engagement
Infrastructure
   PPP progress has been slower than anticipated in
    2010 due to the funding difficulties by developers
   HSE Board approved 210 locations under the PPP
    initiative.
   HSE has signed 12 lease agreements, 23
    Agreements to Lease and 82 letters of
    intent.
   12 locations have been completed within the
    past 12 months accommodating 17 PCTs
   A further 42 have been identified to be completed
    in 2011
   By 2013 - 115 PCCs operational supported by
    160 PCTs
Integrated Working with
Acute
  Essential that Acute and Primary Care Services are a seamless service –

     PCT first point of contact
        with patient
        Acute Hospital Service
        Post Admission


     Chronic Disease Management
        Shift from episodic acute hospital care
        integrated care focused on primary care.


     Hospital Integration
        Discharge planning
        Shared care – diabetes, asthma
        Current hospital care to be provided in the community e.g. cancer
          initiative, minor surgery
        Access to Diagnostics
        OPD direct access to hospital
Primary Care Team Development


   Target to have 527 Teams in place by end of
    2011

   Plan to create 134 Health and
    Social Care Networks
Steps to Primary Care Development…
 Step 1 – Develop PCTs Foundations
  (complete by end 2011)
 Step 2 – Strengthen functionality of
  Teams
       Identify and address staffing deficits
       Strengthen team working though training or
        otherwise
       Implement standard business processes
       Complete health needs assessment &
        strengthen community participation
       Hold regular CTMs with log of care plans
Steps to PC Development…(cont’d)
   Step 3 – Development of Network Services
       Implementation of governance and management
        structures.
       Alignment of specialist and care group services.
       Implementation of general principles of referral and
        shared care arrangements with secondary care, care
        group and specialist services.
   Step 4 - Develop health promotion and proactive
    services within the team
       Roll out of Chronic Disease Management
       Falls prevention programmes
       Locally targeted programmes
Supporting Developments
   Management and Clinical Governance
   ICT
   Chronic Disease Management
   Community Needs Assessments – guidance doc
    nearing completion
   Reconfiguration of Admin staff Plan
   Resource Pack for PCTs
   DVD
   Community Engagement Guidelines
   Pharmaceutical Engagement Guidelines (draft)
Primary Care Performance Activity
   350 Teams in operation at end of December 2010
    (89% of 2010 target)

   Additional 31 Teams holding multi-disciplinary
    clinical meetings between HSE staff without GPs

   2,615 Staff assigned to functioning Teams

   Over 1,309 GPs participating on Teams
Primary Care Performance Activity &
Performance Indicators cont…
   ICT Supports – Hardware requirements, work with GPIT
    group to progress secure e-mail

   Enhancement of Primary Care Services –
      Community Intervention Teams
      IV Therapy
      Falls Prevention
      CMHTs
      Smoking cessation
      Breast feeding training for PHNs


   Prescribing (QCCD) – cost effective prescribing choices
Primary Care Performance Activity &
Performance Indicators cont…
   Cancer Services
      training for practice nurses in cancer prevention care,
      community nurse education programme further developed,
      information/training sessions for GPs and
      electronic referral cancer systems developed within the GP
       software packages

   Chronic Disease Management (QCCD) – Commencement of
    Clinical Leadership for primary care & Guidelines for disease
    management for 7 priority programmes pertinent to Primary Care
    –
      Stroke
      Heart Failure
      Asthma
      Diabetes
      COPD
      Dermatology/Rheumatology
      Care of the Elderly
Chronic Disease Management in
Primary Care
   Most of the care of patients with chronic conditions takes
    places within the primary healthcare sector. This includes:
       Diagnosis, treatment and rehabilitation of patients with chronic
        conditions;
       Early detection, assessment and follow-up comprehensive
        medical treatment
       Preventive activities including smoking cessation, dietary
        advise and support of patients’ self care.

   Estimated 15-16 million consultations in general practice
    while approximately 1.9 million consultations take place in
    out-patient departments each year.
Why focus on Chronic Disease
   80% of GP consultations
   60% of hospital bed days
   2/3rds of emergency medical admissions to hospitals.
   8 of the top 11 causes of hospital admissions are due to
    chronic diseases
   5% of inpatients with a long-term condition account for
    42% of all acute bed days.
   CDMP - 50% reduction in unplanned hospital admissions as
    well as a 50% reduction in bed day rates
Falls Prevention
   34,000 treated per year due
    to falls = 703,000 bed days
   Hip fractures – €35m per year
   2 out of 3 over 65 who
    fracture hip never return
    home
   Falls Prevention
      PCT delivered
      >25 PCT’s delivering Fall
        Programmes
      Programmes reduce falls
        by 15 – 30 %
   Potential savings: €17.5 m
Diabetes
   10% total healthcare
    budget -700m per year

   Complications of DM cost
    €696m per year

   4.1% reduction in Stroke/
    MI in a 3 year structured
    DM programme
Heart Failure
A structured shared care model
   between Primary Care/
   Hospital would prevent:

   > 4,000 hospitalisations per
    year

   free up 50,000 bed days.

   Equivalent to building a small
    to medium size hospital at a
    cost of €27m.
Asthma
   5,000 admissions
    per annum

Structured Primary
  Care Model
  (Finland)
 54% reduction in
  hospital bed days
 90% reduction in
  deaths
COPD

   Estimated by 2020 COPD will be third leading cause of
    death worldwide.
   2003 - COPD caused 4.9% of all deaths in the UK
   At least 10% of emergency admissions to hospital are
    COPD related
   Average hospital stay of nine days per exacerbation, three
    to four times a year
   Integrated care intevertion including education, co-
    ordination among levels of care and improved accessibility,
    reduced hospital readmissions in COPD after 1 year.
Stroke
     Rates in Irish Population
          Stroke: 1.93/1,000 pop. (NDPSS)/ TIA: 0.62/1,000 pop. (NDPSS)
          10,817 new stroke/TIA nationally per year- 1 every hour

     Stroke/TIA Hospital Bed Use
          9,570 hospital admissions/yr (2000-06, HIPE)

     Stroke/TIA Combined:
          5% of all hospital bed days (HIPE, 2000-06)

     Estimated 2009 Total Direct Costs - €405m

     Atrial fibrillation
          Atrial fibrillation (irregular heartbeat) in 10-20% of over-70s
          Extensive brain injury  disability, NH care common
          30% of all stroke (NDPSS, INASC)
          Easy and inexpensive to detect (pulse, ECG)
          70% preventable (blood-thinning anticoagulation)
          Only 25% of known AF treated (NDPSS)
          600 missed opportunities - potentially-preventable severe strokes in 2006
Benefits of Primary Care Team
Improved service to the client
 Safer more co-ordinated care
 Clearly identifiable for patients
 Named Nurses, physiotherapists, occupational therapists, social
  worker on the team, relationship building
 Shorter waiting times for Occupational Therapy, Physiotherapy,
  Social Work
 Range of services provided increased
 Increased clinical contacts with clinical rooms
 Single referral form/self referral
 More focus on:
      health promotion
    disease prevention
Improved communication and information sharing
 Communication with other agencies e.g. hospitals, voluntary
  groups and community groups
Benefits to staff: high staff retention levels
Benefits of PCTs cont…
    Local personal relationships with clients/patients
    Community-based services near patients’ home
    Better use of the clinical skills of the various professionals;
    Identify and tackle critical local health issues e.g. suicide prevention;
    Less duplication and fragmentation in the health system due to better
     communication structures;
    Decrease hospital attendance through the delivery of chronic
     disease management programmes
    Transfer services from acute hospitals to the community e.g.
     diagnostics, minor surgery, wound management, IV therapy in the
     community;
    Facilitate early discharge through the delivery of CITs, pre-hospital
     and discharge planning, timely access to appropriate multi-disciplinary
     services in the PCTs;
    Support patients in the community e.g. falls prevention programme;
    Offer multidisciplinary health promotion initiatives
    De-stigmatise the provision of Mental Health services in the
     community
    In complex cases a Key Worker navigates health system on behalf of
     the patient
Feedback on Development to date…..
 Lack of Resources: Those teams without
  premises feel very strongly about this
  position and feel they will not work as a
  “team” until this is rectified.
 The moratorium is leaving teams without
  resources and this has been identified as a
  key risk in a number of teams.
 Lack of basic IT equipment coupled with
  no administrative support is impinging
  on team effectiveness.
Next Steps…
   Continue roll out of PCTs
      Staff reconfiguration
      Engagement with GPs
   Strengthen exiting Primary Care Teams
      Implementation of governance arrangements
      Strengthen team working though training or otherwise
      Implement standard business processes
      Complete health needs assessment
   Primary Care Centre Developments
   Development of Performance Metrics
   PCT Needs Assessments
   Progress Engagement with Acute
   Develop Health and Social Care Networks
   Roll out of Chronic Disease Management Programmes
   Updated and clear information needs to be communicated to the
    public, PCT members, and HSE literature and websites.
We know

  Patients feel they get a better service from a
   multi-disciplinary team
  Staff are happier working in well functioning
   teams
  Happier staff deliver better services
  Countries with advanced health systems are
   moving to this way of working
Discussion….

				
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