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The journey -

This programme’s purpose was to create inter-operability between a range of clinical systems that capture patient records.  These include GP, out-of-hours, A&E, social care, minor injuries units and mental health services.  It was recognised that similar clinical systems existed in a number of these organisations (replacing paper patient records) and the opportunity was identified to extend their inter-connectivity to improve point of delivery care. The programme aimed to create a summary view of patient records, safely accessible to a range of health and social care professionals. Although at its heart is an IT solution, the change is less about technology and more about a range of organisations agreeing and working towards a shared vision, which involves learning to work in different ways.  Behavioural and cultural change are seen as essential components in its successful delivery.  

Outcomes

Outcomes to date include closer integration and working relationships on all aspects of IT delivery and cross-professional co-operation; for example between clinicians and IT.  There has been significant learning about cross-functional collaboration, including creating a shared vision and influencing multiple partners.  

Patient setting

In-patient Out-patient Community based   X
Mental health Chronic illness Cross-systems   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care X
Planned care Mental health X Long-term conditions End of life
 

Information, tools and techniques used

No information available.  

Geography

Avon Information Management and Technology Consortium (AIMTC) is a shared service over NHS Bristol, North Somerset and South Gloucestershire (BNSSG).   Other participants in the programme include Bristol City Council (social care), North Bristol NHS Trust, Weston Area Heath Trust and University Hospitals Bristol.  Also involved are a number of voluntary community organisations and social enterprises.  

Timescale

Active work on the programme has been underway since 2010. It is now in its procurement phase, during which clinical partners were involved in assessing a shortlist of suppliers.  

Contact details and further information

Andy Kinnear, Head of Avon IM&T Consortiums: andy.kinnear@aimtc.nhs.uk

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The journey -

Safe, Supportive and Therapeutic Care aimed to improve safety and care within acute inpatient mental health units; to minimise risk while maximising therapeutic benefit. A secondary but related objective was to reduce length of stay in acute inpatient units. Strands of work covered three key areas: clinical skills and interventions; policies, procedures and systems; and environmental security. Specific activities included a thorough review of clinical evidence and of policy and procedures; staff training and a ligature audit to identify and remove any environmental elements contributing to increased risk of patient suicide.  

Outcomes

The programme has achieved a wide range of improvements, including better clinical risk assessment and collaborative and patient focused care plans. Each acute inpatient environment has been assessed using an accredited ligature audit tool with high risk ligature points being addressed first and processes identified to modify medium and low risk points. The programme has created a stronger identity and culture within Acute Care, as well as greater clarity among the different professions (psychology, nursing, occupational therapy and medical) about their role and contribution to providing high quality care.  There is now greater consistency of care across acute units and the programme has also achieved its overarching aim, which was to minimise risk while maximising the therapeutic benefit of inpatient care.  

Patient setting

In-patienta Out-patient Community based
Mental health   X Chronic illness Cross-systems
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care   X
Planned care Mental health   X Long-term conditions End of life
 

Information, tools and techniques used

Whilst some general principles of change management underpinned the programme, it did not follow a formal change model. Different change management processes included a ligature audit which used a validated tool to assess environments as well as consulting nationally in order to learn from good practice elsewhere. The review of risk policy, training and redesign of risk tools was informed by a full consultation within the trust.  

Geography

The programme was run across the six acute inpatient units and six crisis teams working in the community across the Sussex Partnership NHS Foundation Trust.  

Timescale

The programme was initiated in March 2010, and by April 2012 most of its key elements had been implemented.  

Contact details and further information

Theresa Dorey, Nurse Consultant/Professional Lead, Acute Care.

theresa.Dorey@sussexpartnership. nhs.uk

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The aims of the Partnership -

The Sussex Dementia Partnership is a clinically-led collaboration between the health and social care commissioners and providers of Sussex involved in Dementia care. It aims to transform dementia services in line with the National Dementia Strategy (NDS) in order to improve the experience of people with dementia and their carers. Dementia is a significant and increasing financial burden in Sussex. There are different commissioning and provider arrangements for dementia across Brighton & Hove, East Sussex and West Sussex. Evidence suggests that working collaboratively across organisational and geographical boundaries to implement the dementia transformation programme with a QIPP focus could enable Sussex to meet future challenges against a backdrop of financial constraint, and this has led to the formation of the Partnership. The vision of the programme is to achieve improvements in the following areas:
  • The experience of people with dementia and their carers
  • Early diagnosis of dementia and access to information and support
  • Numbers of people treated (within existing resources) in order to meet significant demographic increases over the next 10 years
  • Improved care in the general hospitals, plus a reduction in inappropriate admissions and length of stay
  • Improved care in care homes
  • Access to dementia crisis support at home services
  • Reduced inappropriate use of anti-psychotic medication
  • Reduced unwarranted variation in services across Sussex
 

Outcomes

There has been significant progress in delivering the NDS. A full Memory Assessment Service with Dementia Advisors has started in West Sussex and procurement is also underway in the other localities meaning that full coverage will be achieved by April 2013. The quality of care in general hospitals has improved notably; Older People’s Mental Health Liaison services have been extended across Sussex and the innovation of a Dementia Shared Care Ward is being spread to other hospitals. All four acute trusts have developed Dementia Strategies and are making progress in delivering improvements in education, environment and person-centred care. A Sussex wide dementia acute audit has provided the system with valuable information about the dementia profile in the hospitals and preventative approaches to admission. In care homes, a Sussex-wide service has been developed to focus on medication review and non-pharmacological approaches to challenging behaviour. This has led to quality improvements and reductions in anti-psychotic prescribing. Achievements have also been made in dementia crisis support services at home. Finally, work is in progress to improve services for people with dementia at end of life, to increase carers’ support and to provide education for the system in relation to reducing anti-psychotic prescribing.  

Patient setting

In-patient   X Out-patient   X Community based   X
Mental health   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care   X
Planned care Mental health    X Long-term conditions   X End of life   X
 

Information, tools and techniques used

The National Dementia Strategy was published in February 2009 and there was widespread belief that the strategy could not be implemented effectively by individual organisations in isolation. The concept of a partnership approach was initiated by CEOs and senior clinicians within Sussex, with the Director of Social Care and Partnerships South East acting as a catalyst to bring the different parts of the system together. The principles of the Academy for Large Scale Change model were utilised, focusing on mobilising, spreading and sustaining change. Whole system modelling was undertaken to understand the impact of implementing the NDS on demand and resources.  

Geography

Across the local authorities of Brighton & Hove, West Sussex and East Sussex.  

Timescale

The Sussex Dementia Partnership was set up in January 2010, following initial meetings during 2009. A programme manager was jointly funded by NHS Sussex and a Delivery Board established. A two year independent evaluation of the Partnership will be completed in October 2012 and this will form part of a review of the future of the Partnership in the light of the transition to clinical commissioning.  

Contact details and further information

Contact Charlotte Clow, Sussex Dementia Partnership Email charlotte.clow@nhs.net [post_title] => Sussex Dementia Partnership [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => sussex-dementia-partnership [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:55:40 [post_modified_gmt] => 2013-01-16 14:55:40 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3402 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 3396 [post_author] => 8 [post_date] => 2013-01-16 14:44:05 [post_date_gmt] => 2013-01-16 14:44:05 [post_content] =>

The journey -

This programme established a new admissions unit, the Rapid Assessment & Consultant Evaluation (RACE) ward.  Here medical patients with geriatric needs (frailty, multiple co-morbidities, advanced age dementia) referred to hospital as emergencies, are assessed and cared for by a consultant-led multidisciplinary (MDT) team, including doctors, nurses, physiotherapists, occupational therapists and community support staff. All patients receive comprehensive geriatric assessment (CGA) within 24 hours of admission and there is a daily multidisciplinary meeting attended by the ward team and representatives from Poole Intermediate Care Service, Poole Social Services and Dorset Social Services to facilitate discharge planning. GPs can also refer patients to the daily emergency clinic held on the ward to access rapid diagnostics and CGA without admission to hospital. The aim of the unit is rapid comprehensive assessment of older patients with complex needs. This facilitates early supported discharge and avoids unnecessary hospital stays which can be detrimental to older patients. The trust benefits from a reduced length of stay for older patients with concomitant savings.  

Outcomes

Within 3 months of the establishment of the RACE ward marked improvements were recorded. Patient discharge within 48 hours increased from 20{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} to 40{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}, and average length of stay decreased from 19 to 13 days. The quality of patient care also improved as a result of comprehensive geriatric assessment at the front door.  

Patient setting

In-patient   X Out-patient Community based
Mental health Chronic illness   X Cross-systems   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care    X
Planned care    X Mental health    X Long-term conditions    X End of life   X
 

Information, tools and techniques used

The original impetus for the change was managerial, but the change was driven bottom up: planned, led and implemented by clinicians.  

Geography

The change took place in Poole Hospital, Dorset.  

Timescale

The change took place in June 2010 and lasted 6 weeks from planning to implementation. Now fully embedded, the operation of the RACE ward has continued to develop and evolve.  

Contact details and further information

Prem Fade, Department Director: Prem.Fade@poole.nhs.uk [post_title] => Rapid Assessment & Consultant Evaluation (RACE) [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => rapid-assessment-consultant-evaluation-race [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:44:05 [post_modified_gmt] => 2013-01-16 14:44:05 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3396 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 3393 [post_author] => 8 [post_date] => 2013-01-16 14:35:00 [post_date_gmt] => 2013-01-16 14:35:00 [post_content] =>

The journey -

The aim of this programme was to implement an integrated plan for the care of the frail and elderly with the aim of reducing hospital admissions.  Many older people were finding it difficult to access the right services, so part of the aim was to simplify and co-ordinate care for this group of patients. The first steps were informal conversations among interested parties.  This led to the formation of a local strategic partnership spanning health and social care specialists.  The programme looked at all areas relevant to patients aged over 65, learning disabled and other vulnerable people.  These included dementia, end-of-life care, balance classes to reduce falls and ‘living well at home.’  

Outcomes

The programme is still ongoing, but there is some evidence of fewer hospital admissions in this age group.  Another benefit has been improved relationships between strategic partners and considerable learning in areas such as aligning finances, outcome measurements, assessment processes and the politics of organisational relationships.  

Patient setting

In-patient Out-patient Community based   X
Mental health   X Chronic illness   X Cross-systems   X
 

Clinical area

Staying healthy   X Maternity and newborn Children and young people Acute care
Planned care Mental health    X Long-term conditions    X End of life   X
 

Information, tools and techniques used

The programme started with informal networking among interested parties and progressed to a more formal local strategic partnership.  Specific change management tools were not used.  

Geography

Crawley area including Crawley Borough Council; Crawley CCG; West Sussex County Council; Sussex Partnership Foundation Trust and voluntary groups.  

Timescale

The programme is still ongoing.  

Contact details and further information

Dr Amit Bhargava, GP Principal, Southgate Medical Group, Crawley: amit.bhargava@btopenworld.com [post_title] => Integrated care of the frail and elderly [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => integrated-care-of-the-frail-and-elderly [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:37:39 [post_modified_gmt] => 2013-01-16 14:37:39 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3393 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 5 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 3423 [post_author] => 8 [post_date] => 2013-01-16 16:07:12 [post_date_gmt] => 2013-01-16 16:07:12 [post_content] =>

The journey -

This programme’s purpose was to create inter-operability between a range of clinical systems that capture patient records.  These include GP, out-of-hours, A&E, social care, minor injuries units and mental health services.  It was recognised that similar clinical systems existed in a number of these organisations (replacing paper patient records) and the opportunity was identified to extend their inter-connectivity to improve point of delivery care. The programme aimed to create a summary view of patient records, safely accessible to a range of health and social care professionals. Although at its heart is an IT solution, the change is less about technology and more about a range of organisations agreeing and working towards a shared vision, which involves learning to work in different ways.  Behavioural and cultural change are seen as essential components in its successful delivery.  

Outcomes

Outcomes to date include closer integration and working relationships on all aspects of IT delivery and cross-professional co-operation; for example between clinicians and IT.  There has been significant learning about cross-functional collaboration, including creating a shared vision and influencing multiple partners.  

Patient setting

In-patient Out-patient Community based   X
Mental health Chronic illness Cross-systems   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care X
Planned care Mental health X Long-term conditions End of life
 

Information, tools and techniques used

No information available.  

Geography

Avon Information Management and Technology Consortium (AIMTC) is a shared service over NHS Bristol, North Somerset and South Gloucestershire (BNSSG).   Other participants in the programme include Bristol City Council (social care), North Bristol NHS Trust, Weston Area Heath Trust and University Hospitals Bristol.  Also involved are a number of voluntary community organisations and social enterprises.  

Timescale

Active work on the programme has been underway since 2010. It is now in its procurement phase, during which clinical partners were involved in assessing a shortlist of suppliers.  

Contact details and further information

Andy Kinnear, Head of Avon IM&T Consortiums: andy.kinnear@aimtc.nhs.uk

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Category: Mental health

Avon Connecting Care

The journey – This programme’s purpose was to create inter-operability between a range of clinical systems that capture patient records.  These include GP, out-of-hours, A&E, social care, minor injuries units and mental health services.  It was recognised that similar clinical systems existed in a number of these organisations (replacing paper patient records) and the opportunity […]

Posted on Jan 16th Cat: , , , , Tags: , Comments: Comments are off for this post

Safe, Supportive and Therapeutic Care

The journey – Safe, Supportive and Therapeutic Care aimed to improve safety and care within acute inpatient mental health units; to minimise risk while maximising therapeutic benefit. A secondary but related objective was to reduce length of stay in acute inpatient units. Strands of work covered three key areas: clinical skills and interventions; policies, procedures […]

Posted on Jan 16th Cat: , , , Comments: Comments are off for this post

Sussex Dementia Partnership

The aims of the Partnership – The Sussex Dementia Partnership is a clinically-led collaboration between the health and social care commissioners and providers of Sussex involved in Dementia care. It aims to transform dementia services in line with the National Dementia Strategy (NDS) in order to improve the experience of people with dementia and their […]

Posted on Jan 16th Cat: , , , , , , , , Comments: Comments are off for this post

Rapid Assessment & Consultant Evaluation (RACE)

The journey – This programme established a new admissions unit, the Rapid Assessment & Consultant Evaluation (RACE) ward.  Here medical patients with geriatric needs (frailty, multiple co-morbidities, advanced age dementia) referred to hospital as emergencies, are assessed and cared for by a consultant-led multidisciplinary (MDT) team, including doctors, nurses, physiotherapists, occupational therapists and community support […]

Posted on Jan 16th Cat: , , , , , , , , Comments: Comments are off for this post

Integrated care of the frail and elderly

The journey – The aim of this programme was to implement an integrated plan for the care of the frail and elderly with the aim of reducing hospital admissions.  Many older people were finding it difficult to access the right services, so part of the aim was to simplify and co-ordinate care for this group […]

Posted on Jan 16th Cat: , , , , , , , , Tags: Comments: Comments are off for this post