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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.

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Community Team +

The story so far…….

Two phases of work t

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
The team complex needs ? (CHECK)

We assembled a core team covering all partner agencies, we had:

  • Occupational Therapists

  • Social Workers

  • TelecareCoordinator

  • GP Practice Manager

  • Housing Scheme Coordinator

  • Project Manager

  • District Nurse

  • Community Matron

  • Community Support Manager

  • Revival Hope improvement Case Worker

  • ASC Strategic Manager

Where we went
Where We Went complex needs ? (CHECK)

Shelton Primary

Care Centre

University Hospital of North Staffordshire

A & E

Community Health

Services – (District

Nurse, OT)

Social Care



Contact Centre



Single Point of Care

The Story of ‘B’…… complex needs ? (CHECK)

Social Care






Partner-ship Trust

B vital statistics
B – vital statistics….. complex needs ? (CHECK)

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

Assessments and referrals
Assessments and Referrals? complex needs ? (CHECK)

Total Assessments B

Total No. of assessments - 74

Different assessment types - 29

Causing Failure

and Waste?

What complex needs ? (CHECK)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’

Learning from mapping b
Learning from mapping ‘B’ complex needs ? (CHECK)

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 complex needs ? (CHECK)

from the citizen’s perspective?



Not me/

Not here


I need help!






I’ve had all these assessments and my problem still isn’t sorted!

And the cost a year of care
And the cost…..? complex needs ? (CHECK) a year of care

During the most recent full calendar year:

  • Cost the whole system at least £38K (but consider the additional value of B’s brother and sister-in-law’s support)

    During year of care April 11 to March 12:

  • 236th most costly patient out of 107,000

  • just one of 2,145 patients who cost Health providers at least £20K a year

Exceptional / Unlucky?? complex needs ? (CHECK)

  • Other professionals say they all know a number of B’s…..

  • ‘B’ only the 12th highest user of the Telecare service

  • WMAS state B ‘not on their radar’ as a high intensity user

  • Analysis of 10 patient journeys/cohort of assessments for Hospital Discharge reveals common themes of:

    • Warning signs not recognised/acted on

    • Limited lines of sight

    • ‘Pass the parcel’/not my role

    • Difficulty accessing the right help at the right time

    • Service shaped assessments and provision – that miss the point

    • Analysis of ASC referrals suggest a ‘weak’ approach to prevention.

The opportunity
The Opportunity…… complex needs ? (CHECK)

  • Effectively addressing what matters to B and addressing primary sources of waste1 could have saved £10k (25%) during his most recent YoC

  • Extrapolated across the cohort of 1700 service users costing 20 to 40k per annum2, an average saving of only15% would generate £6.9 millionper annum (including tier 5 = £15 million)

  • Addressing system inefficiencies could offer further financial benefits

  • Avoidable admissions/bed days whilst waiting for a PoC; ambulance call outs; telecare activity

  • From the Apr 2011 – Mar 2012 LTC YoC data

So what happened when we started to do things differently? complex needs ? (CHECK)

Feedback from Plan

Starting with understanding
Starting with understanding complex needs ? (CHECK)

…..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


… 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…… complex needs ? (CHECK)

Triangle of complexity / need








Low to high



Case study z a frequent flyer
Case study Z – a Frequent Flyer complex needs ? (CHECK)

The Burns Curve complex needs ? (CHECK)

‘Z’ starts to wobble- Eventual Cancer diagnosis

Living well, delivering

what matters


April 10

June 11

November 11

May 12

December 10

May 10

January 11

November 12

January 12

Historical consumption


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

October 12

January 13

February 13

December 12


March 13

April 13

C+ Intervention


Multiple missed opportunities before intervention

= UHNS stays

= A&E attendances

Deterioration or

premature death

What matters to ‘Z’ complex needs ? (CHECK)

Understand ‘What Matters’

Arranged ‘day sit’ to avoid admission

Traced daughter

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

But for our intervention
But for our intervention…? complex needs ? (CHECK)

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

  • Clare to do

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


  • Timely funding and placement finding – due to time invested ‘up front’ and good understanding of Z – 10 to 14 bed days saved?

  • Improved management of clinical condition = more appropriate resource utilisation

Economic impact complex needs ? (CHECK)

Note acute costs stabilisation

Intervention with ‘Z’

PLAN was hard (TREACLE, CULTURE complex needs ? (CHECK)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 complex needs ? (CHECK)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…

‘What matters‘ compendium understanding…..

Clinical – understanding condition & meds

Carers & their wellbeing

Blockages Encountered – T&F understanding…..

Treacle log (or what we need to fix…)

What we learnt about skills
What We Learnt About Skills understanding…..

The skills we will need….

The ‘Good’ Stuff – Our understanding…..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

Where next???? understanding…..