Personalised Care and Health 2020 makes clear that data and technology can play a central part in transforming

outcomes for patients. There is little doubt that the only way to achieve true integration of care will be to ensure

a steady flow of data and information between different parts of the system, for instance. Yet challenges remain:

concerns over consent and the need to ensure interoperability chief among them.

The award is about recognising initiatives where data sharing has made a real difference to patient care –

improving outcomes, experience and supporting patients to look after themselves better – while at the same time

delivering efficiencies.

Entry criteria

The judges will be looking for evidence of:

Data sharing between healthcare professionals and/or between organisations that has improved patient care

and supported improved clinical outcomes

Excellence in information governance including adherence to data protection and other information

legislation

A clear focus on data quality, data collection and data presentation

Data being used to inform strategic decision making

Demonstrable benefits to the patient

Evidence that clinicians have been engaged in – or preferably led – the initiative to better share data and

information

Proof that best practice has been identified and built upon

All entries will also be submitted to the most effective adoption and diffusion of existing best practice category.

For criteria, please see here.

Project Title: Using technology to manage patient flow across organisational boundaries to support admission avoidance and hospital discharges Full Organisation Name: Lincolnshire Community Health Services NHS Trust Technology is enabling the radical transformation of patient flow across multiple health and care organisations in Lincolnshire. Working to support admission avoidance through proactively managing care to avoid unnecessary hospital stays, it also supports a planned and timely discharge from acute inpatient services into the community through sharing capacity in real-time. Lincolnshire Community Health Services NHS Trust (LCHS) has implemented a patient flow management solution from Cayder, but for the first time has opened its reach to cross organisational boundaries. This includes LCHS, United Lincolnshire Hospitals NHS Trust, Lincolnshire Partnership NHS Foundation Trust and Lincolnshire County Council and by the end of 2015, it is planned for GPs sitting in Neighbourhood Teams (multi-disciplinary, multi-organisational teams being piloted in Lincolnshire) to have access. Teams across organisations now have a complete picture in real-time of:

caseloads

bed capacity

planned availability

rapid response capability

planned acute discharges A RAG board also provides an at-a-glance perspective of multi-agency capacity across the entire geography.

Improved Patient Care/Clinical Outcomes

Before this system was created and implemented, organisational-wide capacity could only be obtained by contacting individual teams and services. However, constantly fluctuating information quickly became outdated. The idea for using the software was first explored as part of a need to better manage patients during winter pressures in 2013/14. At first, this solely supported admission avoidance, with the IT supporting a ‘Contact Centre’ acting as a single point of access for health professionals seeking alternative community-based services. It was quickly exploited and extended into discharge planning at the county’s acute hospital trust, enabling quicker, more effective discharge into community. Benefits

Supports delivery of simplified referral pathways.

Discharge hub gives community services visibility to pro-actively in-reach, see what care is being provided and plan for patient discharge and the services required. From January 2015 to date, this has supported improved management of more than 300 discharges.

Facilitates quicker access to the start or continuation of care.

Patients benefit from a smoother, more seamless and timely transition between services and providers.

Improved communication has allowed for: o more time spent on clinical activity o more effective working with colleagues in other organisations removing silo working o more patients avoiding unnecessary hospital stays and/or reduced inpatient stays

Information Governance

There are now more than 500 individuals accessing the software in Lincolnshire and more than 10,000 distinct patients being managed within the system. It requires no linkage to existing clinical systems, focusing solely on patient flow and status management. It has a security model which ensures individuals only have role-based access to appropriate information. The system is hosted on Lincolnshire’s NHS N3 network, which allows data to be transferred and accessed securely by providers. Information Governance responsibility remains with the NHS providers, and the system’s use is aligned to established and robust IG policies.

Data

Our success is reliant and driven by consistent, reliable data, which users can access in real-time.

Clinicians are no longer reliant on spreadsheets, face-to-face or verbal contact across a rural geography. This real-time data can be accessed and viewed from anywhere on any device and is currently being accessed in acute, community and remote settings using e-whiteboards, PCs and mobile devices. This whole system approach also helps to minimise assessment rework and unnecessary duplication as patients cross service and organisational boundaries.

Strategic Decision Making The information supports workforce and caseload planning so capacity can be better managed. During winter 2014/15, the capacity reporting tool proved effective for senior staff members managing high demand. Live capacity information was taken to multi-agency planning meetings (similar to gold-silver-bronze command structures used for emergency planning) and used to plan service delivery and staffing to enable care to be managed in the right time and place. It also proved flexible with the incorporation of acute escalation beds.

Patient Benefits

Using the software directly supports a multi-organisational proactive approach to admission avoidance and early planning for smooth transition to onward care from discharge.

Over the New Year week in 2014/15, 289 hospital admissions were avoided and 337 discharges supported through referral calls taken by the Contact Centre.

Smoother, more seamless transition of care by joining up service providers.

Streamlines communications process which ultimately supports patients to receive the right care, in the right place and at the right time. Patients should not be directly aware of this “behind the scenes” activity to manage their care, but success will be evidenced longer term through improvements in patient experience and satisfaction, collected on an ongoing basis through measurements such as the Friends and Family Test, patient surveys and anecdotal feedback.

By incorporating information from multiple providers, it improves workforce communication and promotes consistency in the data at hand, allowing staff to spend more time on clinical actions. We estimate a 20 minute saving in onward care planning time per patient by safely and securely sharing information.

Use of the software in conjunction with the Contact Centre, has also broadened staff horizons to encourage the use of alternative community-based health and care services, which are more appropriate for the patient needs.

Engagement

The system was developed in partnership with Cayder who ran a series of workshops with key

staff to review current processes, those they aspired to and then configure a new system that

would help them save time and streamline processes.

The rollout was:

o led by a team at LCHS, which included clinical and non-clinical staff

o overseen and scrutinised by a multi-organisational Urgent Care Board

o subject to an independent evaluation by the University of Lincoln for the Urgent Care

Board, which recognised its successful integration to existing processes and potential to

contribute to ongoing successful system management. It recommended ongoing

continuation of funding.

Ongoing review with users led to organic development and supported the identification of further potential uses.

Best Practice The implementation of the system has:

supported a review of information sharing processes

built on good practice across multiple agencies to simplify pathways and streamline processes

encouraged staff to work differently and more effectively together

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