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Enabling patients to access the right care

A population Health Approach

Dr Phil Wallek Clinical Director Foundry PCN

www.foundryhealthcarelewes.co.uk

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�Lewes Primary Care Home Strategy�

  • Change the way we deliver Primary Care to improve access and keep patients out of hospital
  • Improve continuity with the named GP at the core of this.
  • Small groups of GPs working as Continuous Care Teams (CCT)
  • Complement, enhance and signpost existing services with care navigators
  • Work with our partners to provide access to and co-design a greater range of Health and Social Care services
  • Utilise additional roles, pharmacist, nursing, paramedic, physiotherapy, social work and voluntary sector
  • Locate a GP led Acute team at the Lewes Victoria Hospital to support and enhance the MIU service and community hospital and create a UTC

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Lewes Primary Care Home (PCN) Development Journey

  • 2015 School Hill and St Andrews consider joining in new premises
  • 2016 River Lodge join and agreement to merge all 3 Lewes practices in one building
  • 2016 Estates and Technology Transformation funding successful application
    • Developer promised building complete 2019 (now 2022)
  • 2017 Joined NAPC 2nd wave of Primary Care Home
  • 2017 Development of 1st version patient segmentation RAG 4th Sept (New or ongoing problem)
  • 2018 Proposal of Minor ailments unit (now UTC opened May 2020)
  • 2018 Foundry Healthcare name created
  • 2019 June - PCN formation combined with financial merger of 3 practices
  • 2019 August Development of 2nd version patient segmentation – (Clinician assigned template)
  • 2019 September Combined Acute Hub at River lodge site
  • 2020 May 30th Opening of UTC Acute hub moving to Lewes Vic Hospital
  • 2020 June GMS merger and Merger of S1 Units
  • 2020 June 3rd Version patient segmentation and primary care model (Priority 1,2,3 Assigned to rotas)
  • 2020 July 22nd Move of registered patients and doctors to equalise teams
  • 2022 New Health Hub

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The right care by the right person

  • Standardised vs Interpretive
    • Realising the full potential of primary care: uniting the ‘two faces’ of generalism by Joanne Reeve, and Richard Byng BJGP Volume 67(660):292-293June 29, 2017
    • Simple Care (Standardised)
      • Defined need technical replicable care
    • Complex Care (Interpretive)
      • Uncertain need, expert generalised care

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  • Continuity vs Access
    • Rosen R and Tomlinson J (2019) “How to improve continuity in general practice?”, Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/how-to-improve-continuity-in-general-practice
    • While some groups prioritise continuity of care over quick access, others see an appointment at a convenient time as most important.
    • “Our need and desire for continuity waxes and wanes throughout our life in many different, complex ways” (workshop participant).
    • Definitions
      • Continuity
        • Relational continuity: An ongoing therapeutic relationship between a patient and a clinician, whereby both “know each other well” (Freeman G. 2018, pers. comm.). This is referred to as relational, personal or interpersonal continuity.
        • Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs.
        • Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual (Haggerty and others, 2003).
      • ‘Access’
        • does not easily lend itself to definition either, but can cover physical access, timely access, convenience, and includes choice of practice and professional (Boyle and others, 2010).

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Lewes Primary Care Home (PCN): �Population Health Management

  • The approach we have taken has evolved over as we have implemented change, reflected on this, and then taken further steps based on the lessons learned
  • The approach incorporates three key elements to form a cohesive system:

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Population Health Management

Patient segmentation on the basis of needs

Priority of Demand

Level of Continuity

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Primary Care Patient Streaming Principles:�Red/Amber/Green (RAG) System

Source: Dr Steven Laitner May 2015

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Generally well

Long term conditions

Complexity of LTC(s)

and/or disability

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Low risk

High risk

Low risk

High risk

Low risk

High risk

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Children and Young People

  • Neonates
  • Infants
  • Toddlers
  • Children
  • Adolescents

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Working Age Adults

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  • Young
  • Middle aged
  • Older working age

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Older People

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  • 65-80
  • 80-90
  • 90+

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Dementia

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Continuous Care Team

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Acute Team

Long- term

Condition

Team

Multi-Agency

Team

Individual GP’s in the CCTC are named GP’s for all patients and so form the glue between the teams as they are part of all of the teams

Mental Health Team

Safegaurding

Disease Prevention

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This template is used at the end of each consultation to review the patient group (Red, Amber, Green) as outlined in the slide above and the usual GP.

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This acts as both as an administrative review but also as a moment of contract between the clinician and the patient – I am recognising your need and committing to walk with you in this.

Patient Group Template

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Patient-led Demand Priority Level

  • Differentiating contact type allows identification of on the day needs
  • Shows which appointments can be moved during holidays or busy periods
  • Can be used for patient contacts and workflow management
  • Based on a presumption of a defined mix of urgent and non urgent needs
  • Both urgent and non urgent need to be met. Non urgent work can be moved
  • Similarities to Hospital organisation: A+E, 2 week wait, Routine outpatients.

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1

On the day e.g. acute illness, urgent prescription requests, urgent ongoing issues

2

In a week e.g. less urgent new illness, ongoing problems, medication queries

3

In a month e.g. non-urgent new illness, follow up, results

4

Within 6 months e.g. some types of chronic disease reviews

5

In a year e.g. QoF, routine reviews

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Continuity Level

  • Defines which patients should be seen by which team
  • Describes how different practices are organised
  • Describes how larger primary care organisations/PCN’s can be organised to retain continuity
  • Allows understanding of workload
  • Helps define continuity
  • Combines with Patient segmentation and Priority level to define the whole system
        • GP
        • Continuous care team
        • Practice Team
        • Primary Care Network
        • Wider acute services – UTC, A+E

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Continuity Level Cascade

Continuous Care Team

GP

Primary Care Network

Practice Team

Acute Care System

1

2

5

3

4

RED PATIENTS

ORANGE PATIENTS

GREEN PATIENTS

When demand reaches capacity at one level of continuity it cascades down to the next level

RED Demand

ORANGE Demand

GREEN Demand

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Population Health Management Model

RAG System

Continuity Level

Priority of Demand

ROTA

SYSTEM

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Patient Navigator Patient Flow

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Initial Data: Appointment Ratios

  • Week chosen 4th Nov 2019: 1888 total GP/Paramedic contacts defined
  • Analysed to create baseline rota ratio for workforce planning

Green vs Amber vs Red

9 : 10 : 1

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  • Appt length: Green 5min/10min Amber/Red 7.5min/15min

Green vs Amber vs Red

9 : 15 : 1.5

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Appointment Ratios inc. Priority Level (1-3)

  • Green Patient Group

P1F2F:P1Tel P2F2F:P2Tel P3F2F:P3Tel F2F:Tel Time F2F:Tel

4:7 4:4 6:2 14:15 2:1

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  • Amber + Red Patient Group

P1F2F:P1Tel P2FTF:P2Tel P3FTF:P3Tel F2F:Tel Time 2F:Tel

3:7 4:6 4:2 11:15 3:2

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A New Approach for Workforce Planning

  • Doing this initial piece of data gathering enabled us to begin to develop a rota plan that incorporates the three key elements (RAG, Priority, and Continuity Level)
  • This helped us define the expectation of the total number of doctor and paramedic sessions that we aim to provide
  • We then were able to look at this strategically recognising that there are different pressures throughout the course of the year and a key one of those challenges is school holidays
  • Looking at it with this overview and acknowledging the priority of demand means that you can flex the type of service we provide depending on the time of year and staffing levels

Core Clinical Sessions Only

Priority 1-2 Appointments

Core Clinical Sessions

Priority 1-5 Appointments

Specialist Clinics

Management Sessions

Holiday Rota

Standard Rota

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Foundry Healthcare Workforce Planning

  • Standard rota 100 sessions
      • CCT sessions 68
          • Mon 4 CCT, Tues 3 Wed 2 Thurs 2 Fri 3
          • Plus late shift rotating
      • Acute Sessions 42
          • Mon 10 Tues-Fri 8
      • 1661 appts including paramedics
      • 1451 appts without paramedics

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  • Holiday Rota 82 sessions
      • 2 CCT sessions per day per practice
      • Same number of priority 1 and 2
      • 1593 appts
      • Pay back rota either side

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Established Holiday Rules

  • Holiday decided by Practice team 3 monthly meeting with Rota Team attendance
  • After all practice level meetings then review before approval to ensure requests compatible at PCN level
  • If low number 82-100 e.g. Christmas/half term holiday then
    • there would need to be a ‘pay-back’ rota either side to absorb some of the Priority 2 and 3 unmet demand from that week
    • no other holiday taken in the weeks either side
  • If 100 sessions maintained then holiday can be taken either side of the low week

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Amber Rota Design

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Green Hub Rota Design (Including Extended Hours)

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Equivalent Rotas

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Practice Reorganisation of Continuing Care Teams: Stage 1

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St Andrews

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Equalising Workload

  • One driver of workload within the Continuous Care Teams is the patient numbers and the proportions of based in the three RAG categories
  • As part of the teams reorganisation we been going through a bulk move of patients between teams in order to equalise out the numbers
  • We have developed a reference table that is updated monthly that shows the numbers of patients and proportions within each RAG category against:
      • Named GP
      • Continuous Care Teams
  • It also puts this number as against the expected number of patients based on the number of Core Clinical Sessions provided by the clinicians within that team
  • This is used as a reference for GPs to see who they and their team compares to others to inform the numbers of new orange or red patients they take on
  • It also used as a guide for the registrations team to when choosing who to register new patients with

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CCT Reference Table

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Better Data Insight Development with HERE:�Dashboard Giving Live Feedback on the System

  • Improving the data we have on our system to inform how we move forwards has been a key challenge through this process
  • We have done much of the initial analytics ourselves which has been a productive but costly process
  • In 2020 we began partnering with HERE (hereweare.org.uk) who are a Clinical Data Analytics company based in Brighton to bring some deeper analysis of our system
  • The aim is to produce data that will give us a live insight to the stresses within the system and for forecasting and planning how we move forwards
  • This work continues to be in development

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© 2017 National Association of Primary Care