Community Team +. The story so far……. How well does the system currently respond to citizens with complex needs ? (CHECK) How might we better respond to citizens through a holistic approach mobilising the efforts of a broad range of agencies? (PLAN) . Two phases of work… t. The team.
Community Team +
The story so far…….
How well does the system currently respond to citizens with complex needs ? (CHECK)How might we better respond to citizens through a holistic approach mobilising the efforts of a broad range of agencies? (PLAN)
Two phases of work…t
We assembled a core team covering all partner agencies, we had:
University Hospital of North Staffordshire
A & E
Services – (District
Single Point of Care
The Story of ‘B’……
Over the a 2 year period…
7- different agencies involved
30- different teams or professionals gave input
162- acute/sub-acute beds days consumed
72- (at least) of these were ‘excess’ bed days
66- assessments undertaken
869- telecare interventions
Total Assessments B
Total No. of assessments - 74
Different assessment types - 29
What matters to ‘B’
‘I don’t want to go to
bed at 9pm I want to watch films’
‘I really don’t want to go into
hospital or residential care’
‘I want to go out and about, but
I’ve been told to stay in this chair’
‘She dumped me last week, she doesn’t like me like this’
‘Help me live the life I want to lead’
The system doesn’t adapt standard processes
Get it sorted, get it closed
We focus on doing our own bit
Referral system is so complex
Difficult to build relationships
We focus on freeing up beds, not restoring function
We have an episodic culture Assess/Do/Review/Close
We focus on targets
We assess & refer then assume its dealt with
Limited line of sight
Focus on protecting my budget
What does the system look like
from the citizen’s perspective?
I need help!
I’ve had all these assessments and my problem still isn’t sorted!
During the most recent full calendar year:
During year of care April 11 to March 12:
Exceptional / Unlucky??
So what happened when we started to do things differently?
Feedback from Plan
…..for some we need to stabilise the situation before being able to help….
The presenting ‘what matters’ is not always as important as first appears, but…..
Understand what matters
…..it can help the citizen and us understand ‘what really matters’.
…but delivering help allows us to further understand ‘what really matters’
‘Finding’ people was hard……
Triangle of complexity / need
Low to high
The Burns Curve
‘Z’ starts to wobble- Eventual Cancer diagnosis
Living well, delivering
0 bed days
4 A&E costing £388.07
2 bed days costing £1799.48
3 A&E costing £259.62
38 bed days costing £9,803.50
8 A&E costing £1122.45
2013 - on going
41 bed days costing £14,749.00
6 A&E costing £822.48
Multiple missed opportunities before intervention
= UHNS stays
= A&E attendances
What matters to ‘Z’
Understand ‘What Matters’
Arranged ‘day sit’ to avoid admission
Arranged urgent medications
Empowered daughter regarding palliative care
Purchased clothes, food, fruit etc….
Made home environment safe, clean and accessible
Help & Problem
Facilitated C Health Care (CHC) funding
Arranged a haircut!
Arranged fast-track Benefits review
Situation at home was inherently risky – he could have come to serious harm at any point – fire/exacerbation of COPD. But this aside……
Robust plan for COPD/CA management may not have been put in place = further exacerbations/hospital admissions
An appropriate support solution may not have been found so early
He would not have stopped smoking so soon
His psychological/emotional/familial issues may not have been addressed in time for a ‘good’ End of Life
Note acute costs stabilisation
Intervention with ‘Z’
PLAN was hard (TREACLE, CULTURE etc …) but we learnt…
From the service users point of view – this approach works!
This will give us a true understanding of demand and commissioning requirements
We are starting to understand workforce/skills requirements
We can see opportunities for more appropriate/sustainable resource utilisation
For our people – this is liberating, inspiring, more meaningful
The ‘Good Stuff’ – Customer feedback
You have given me faith in the system again
I know you’ll do your best for me
Before CT+ I wasn’t living, I was existing
‘I know if I struggle or feel down or need a chat I can just pick up the telephone’
I was raving mad in my flat. Look at me now!
You’ve put my mind at rest
People have helped give me reassurance. I now feel cared for
I wanted a tidy up, not a make-over!
I thought I was going to die in a hospital bed when I didn’t want to
I don’t usually ask for help but with you I can…
We can start to build a rational model based on proper understanding…..
‘What matters‘ compendium
Clinical – understanding condition & meds
Carers & their wellbeing
Blockages Encountered – T&F
Treacle log (or what we need to fix…)
The skills we will need….
The ‘Good’ Stuff – Our Staff
People have boundless energy when set free to make a difference.
I have developed new skills and grown in confidence!
This approach focuses on ‘what matters’ people and appropriate use of funds
Understanding what matters takes more time upfront but is well worth it!
How you think something is very different than how it really is…
Doing good things is also more efficient