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
   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

           PHN                Phy

                                               PHN                           Phy

      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
  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
                                              Clerical Admin

                Primary Care Team

                  Additional staff:
                 Occupational Therapy
                    Social Worker
          Network Services & Linkages

    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
                               • Alternative
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

   Integrate with acute hospital services - reduce hospital admissions,
    early discharge of patients and chronic disease management
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
   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%
       21% of Teams held 2 CTMs (52        21%                 1

        PCTs)                                                   2
       5% of Teams held 3 CTMs (13 PCTs)
       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
   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
   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
   PPP progress has been slower than anticipated in
    2010 due to the funding difficulties by developers
   HSE Board approved 210 locations under the PPP
   HSE has signed 12 lease agreements, 23
    Agreements to Lease and 82 letters of
   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
  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

   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
       Identify and address staffing deficits
       Strengthen team working though training or
       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
       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
       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
   Falls Prevention
      PCT delivered
      >25 PCT’s delivering Fall
      Programmes reduce falls
        by 15 – 30 %
   Potential savings: €17.5 m
   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

   free up 50,000 bed days.

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

Structured Primary
  Care Model
 54% reduction in
  hospital bed days
 90% reduction in

   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.
     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
    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
    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
  Happier staff deliver better services
  Countries with advanced health systems are
   moving to this way of working

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