Dr Helen Kingston The Frome MODEL OF ENHANCED PRIMARY CARE A new building and fresh start 2013 Frome MADE DIFFERENTLY Frome small enough to innovate large enough to operate at a new scale ID: 1023077
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1. Compassionate Frome a new era of medicineDr Helen KingstonThe Frome MODEL OF ENHANCED PRIMARY CARE
2. A new building and fresh start 2013
3. Frome
4. MADE DIFFERENTLY
5. Frome- small enough to innovate large enough to operate at a new scale.
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7. What is most important?PracticalEmotionalMedicalRecognising the value of relationships and of the whole system working together- creating integration across silos
8. A Population based approachSystematicBASED IN AND PART OF PRIMARY CAREWhole population not cohort {no inclusion or exclusion criteria}Based on clinical assessment of needHolisticCollaborative
9. Working with you to build healthy, supportive communitiesNEWSLoneliness and social isolation are harmful to our health: research shows that lacking social connections is as damaging to our health as smoking 15 cigarettes a day (Holt-Lunstad, 2015). Self management = 8,750-8,755 hours a year Hours with NHS / social care professional = 5-10 in a year
10. The comparative impact of social relationships on reduction in mortality
11. IMPACTImproving patient careImproving working livesCost savings
12. Collaborative Problem solvingComplicated livesRecognition of the complicated nature of human beings and of the interplay between social, psychological and medical need Responding flexibly to the person not their medical conditions- helping individuals to navigate the system
13. CLINICALLY LEDLead from the front line with flexibility to respond to the realities they facePragmaticSolutions focusedOutcomes drivenThere are no management costs in the programme. Clinician time is required to implement the project but there is no overarching management of this.
14. IMPROVING WORKING LIVESEmpowerment of compassionate flexible patient focused response to individuals in need.Creating an integrated cohesive team working across agenciesRecognition that those at the front line are motivated through their desire to help others and improving working lives through enabling them to provide the care they would want for their own family and friends.
15. QUALITY IMPROVEMENTUse of quality improvement methodology to measure and drive effective change. A lead GP in each practice is mentored on a monthly basis in quality improvement methodology, which determines the direction of the project in each practice. This has meant there is rigorous methodology with use of run charts to track process and outcome measures. It also ensures local ownership
16. An example of continuous improvement using QI
17. WHOLE SYSTEM APPROACHCollaborative intergrated workingChanging how we work across local health serviceIntegration and collaborative team buildingBreaking out of silo workingWrapping care around the individualRecognising the importance of relationships for those working in health and for patients and carersBuilding a strong team ethosSupporting patients and carersSupporting those working within the system
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19. WHAT MAKES LIFE WORTHWHILEUnderstanding what matters to patientsTreating staff with kindness too and recognising that we chose to work in health and social care wanting to make a differenceReenabling staff to deliver the care they can feel proud of and that would want for themselves their families and friends
20. Working together to help build healthy supportive communities.
21. Health Connections MendipPractice population of 115,00011 GP practicesHealth Connections Mendip Team employed by Frome Medical Practice on behalf of the 11 Mendip practices2 FTE Area Lead who line manage the Health Connectors and lead on the community development in their area (paid6.5 FTE Health Connectors (paid) Work one to one and support groups that we have set up551 Community Connectors (not paid but people in the community)Working with you to build healthy, supportive communitiesOUR MODEL
22. 344 Community Connectors!Practice population of 115,000Employed by Frome Medical Practice on behalf of the 12 Mendip practices.
23. Working with you to build healthy, supportive communitiesMAP- its opportunities and strengths. We map local support and let people know about this support in a variety of ways. We link patients in Mendip GP practices with non-medical sources of support within the community. This connects people to the assets on their doorsteps. Nearly 400 groups and services listed.Embedded in EMIS so social prescribing at practices’ fingertips.Number of practice based signposts easy to report on across the 12 practices.Website template is replicable so other areas can use it. http://demo.healthconnectionsmendip.orgOver 32,000 views 16-17.OverviewWe start with the assets in the community
24. Working with you to build healthy, supportive communitiesCOMMUNICATEWe recognise that people access support and information in different ways. Our model enables people to find information in the way that suits them best. We let people know about support in a variety of ways.Phone line manned 5 days a weekEmail signpostingLetters to patients on practice registerNewspaper articlesMonthly radio slotAwareness raising stallsWebsite 2016-17 over 32,000 viewsStaff who link to the website via EMIS eg GPs, Health Connectors , Health Care Assistants and ReceptionistsTalking CafesCommunity ConnectorsOverviewThere is so much support out there
25. Embedded in EMIS so social prescribing at fingertips
26. Working with you to build healthy, supportive communities551 Community Connectors. CONNECTIf each Community Connector signposted 20 times a year this would be 11,020 opportunities to support people in our community.11,020 signposting conversations a year.The number of Community Connectors is ever increasing.
27. Connect.Who would make a good Community Connector?
28. ConnectCommunity Connectors are members of the community who know what’s out there and signpost friends, family, colleagues and neighbours to support in their own community. Community Connectors are very effective at integrating with their local communities - providing a bridge between local people and other services and thus building community knowledge.700 Community ConnectorsThousands of people signposted to support.Church congregationsSupermarket staffHairdressersSixth form studentsSupport group members and patientsDrug and alcohol peer support workersPolice Community Support Officers.Care home staff/care workersTaxi drivers Park RangersTown CouncillorsSocial WorkersJob Centre Staff
29. Working with you to build healthy, supportive communitiesBUILDWe don’t just set up self sustaining groups but we can support community development in other ways.Support vol sector development by finding volunteers eg Contact the Elderly, Health Walks, promoting eg Parkinsons Support Group and Somerset Sight.Act as catalysts eg volunteer driver scheme, mental health network.Invite organisations in eg - Bereavement Support GroupEncourage eg Men’s ShedBringing people together eg ASC, My Home My Life and CAB (Practice of the Year)Being open to ideas eg Housing post, Youth PPGTrain eg Compassionate Organisation , network mappingPut on big events - eg Older People’s Event (topic based)Innovate eg Advance Care Planning Conversations in the communityStart partnership campaigns eg End Loneliness in Mendip .- In Partnership
30. Building Social CapitalJust a few examplesSetting up self sustaining groups – Identify and Invite - Macular Degeneration GroupPromoting new groups via identify and invite – Parkinsons.Inviting in - Bereavement Support Group and Walk and TalkBeing a catalyst– car scheme, mental health networkBringing people together – ASC and My Life My Home.Doing the simple thing – Hearing Service, Retirement Gateway “Health Connections has been invaluable in bringing together NHS commissioners and voluntary organisations to map the support available for patients with hearing difficulties. Work is progressing on identifying gaps in provision, and planning ways to support people that may be ‘falling through the gap’. Health Connection’s experience in working with the voluntary sector has been a real asset, sharing ideas for raising awareness and promoting joined up working for the benefit of patients.”Finding volunteers – Contact the Elderly “It has been really useful being able to team up with Health Connections to help raise the profile of Contact the Elderly, and help recruit new volunteers to enable us to get two new groups going”. Promoting services – Somerset Sight Volunteer Visiting Service “We have been most impressed with the ability of Health Connections Mendip to promote a local service so quickly and with so much impact across the whole county and would like to say a big thank you”Being open – Housing postPeers doing it best - Advance Care Planning in the community, Youth PPGStarting bigger campaigns – End Loneliness in Mendip.
31. Building Social CapitalPromoting services – Somerset Sight Volunteer Visiting Service “We have been most impressed with the ability of Health Connections Mendip to promote a local service so quickly and with so much impact across the whole county and would like to say a big thank you”Being open – Housing postPeers doing it best - Advance Care Planning in the community, Youth PPGStarting bigger campaigns – End Loneliness in Mendip.
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33. Stats81%* of (HCM) patients saw an improvement in wellbeing (WEMWBS)83%* of patients saw an increase in PAM score (patient activation)PAM score (initial) average 50.8. Pam score (follow up) average 61.6PAM level (initial) average 1.9. PAM level (follow up) average 2.893%* of patients said they felt more able to access support in the community94%* of patients said they were more able to manage their health and wellbeing or LTC92%* of GP practice staff feel confident that their patients benefit from being signposted to HCM91.4%* of GP practice staff feel that HCM adds value to the service they provide to patientsPlus recording done by wider Mendip Symphony team. eg hospital admissions.*based on those that answered 2015-16
34. Why it worksOne foot in the community, one foot in primary care.Employed by and work for the 12 Mendip Practices. Practice pop. 115,000.Work on new models of care. Mendip Symphony patients and attend MDT meetings – Complex Care, primary care, hospital and Adult Social Care this helps us get the bigger picture.We have a shared EMIS clinical service across the 12 practices where Complex Care GPs, Nurse Practitioners, HCAs and Health Connectors can all input on to the shared care plan.We work on community development.We work with groups and individuals on what is important to them. This may involve goal setting, behaviour change, managing LTCs, linking to the community, network creation, network mapping and network enhancement and/or signposting to other services. We work with people with complex needs through to those keen to maintain good health.We work across the whole community – out in the community, in people’s homes, in primary care, in hospitals.Self referral and referral.Work with the whole community from a young man who is feeling anxious and wants to get a job to an older person who is housebound, has had falls and has lost contact with her family. We are trusted We do what is best for the patientWe are allowed to be creativeWe make mistakes and learn from themPatients feel it belongs to them. Staff enjoy their work.
35. Financial ImpactBackground3 years of implementation of the Frome Model has shown a year on year reduction in the number of emergency admissions and the costs of those admissions.CCG data suggests Frome Medical Practice has seen a decrease of 160 emergency admissions (-6.2%) when comparing the full 2017/18 year with the baseline (2013/14).
36. Quarterly admissions Frome 2013 – 2017
37. WHOLE TEAM APPROACHIntegrated workingPatient empowerment and carer supportNetwork enhancementPrimary careCommunity servicesSocial careVoluntary sectorWe can achieve so much more working together across sectors to support the individual than we can as individual organisations
38. LESSONS LEARNTWe can achieve more together than as individual teamsDon’t underestimate the power of relationships- within teams and for our populationScaling up requires Systematic approach Capacity for multidisciplinary conversationsTake a holistic approach stating with what is most important to the individual.Support carersDO WHAT IS BEST FOR THE INDIVIDUAL WORKS