KNOWSLEY CARE CAMPUSWORKFORCE REDESIGN ENGAGEMENT METHODOLOGY

Presented by: Julie HollandDate: September 2011

Methodology

• Organisation Development Services Population Centric Model for Workforce Planning (ODS 2008).

• Skills for Health - Competency Based Planning tools. (SfH 2011)

JH/MAY11

ODS Model (ODS 2008)

JH/MAY11

Patient Proxy - Fred & Sonia• elderly couple (80+) • live in rented accommodation

(private tenants) with access difficulties, and poor facilities/amenities and poor transport networks.

• have five children 3 very supportive 2 estranged. 1 estranged son is the landlord of their home and rent arrangements are difficult.

• Family dynamics are strained resulting in feuds’, and some complex financial issues.

• both socially isolated and lonely and have 5 pets to manage.

• benefit dependent.• Sonia has diabetes, angina and

epilepsy

• totally dependent on family for her care following a stroke, and is housebound.

• communication difficulties (speech) and depressed although mentally bright.

• Sonia is approaching the end of life and has chronic pain and pressure sores.

• She is a smoker and occasional drinker.

• Fred is Sonia’s main carer• has rapidly declining health due to

neglect. • history of COPD, prostate cancer,

hypertension and arthritis.• struggles to care for Sonia and is

often short tempered, stressed and verbally aggressive and is restricted by his wife’s immobility.

• Fred is an ex-smoker.

4 JH/MAY11

SONIA’S NEEDS

BE PAIN FREE

MONEY WORRIES

WOUND TO HEAL TO TALK & BE LISTENED TO

FEEL SAFE

BE ABLE TO GO OUT

HELP HERSELF

WORRIED ABOUT DYING

5 JH/MAY11

FRED’S NEEDS

HELP WITH SONIA

MONEY WORRIES

TO BE PAIN FREE & ABLE TO BREATHE

TO TALK & BE LISTENED TO

FEEL SAFE

BE ABLE TO GO OUTHELP WITH DOMESTIC WORK

WORRIED ABOUT SONIA DYING

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SONIA’S NEEDS

BE PAIN FREE

HFM A2.4 HFM B1.1 HFM B14.2HFM A2.5 HFM B3.1 HFM B15.1HFM A2.8 HFM B4.3 HFM B15.6HFM A2.9

MONEY WORRIES

HFM 1.5HFM B16.4HFM C2.4HFM C2.6

WOUND TO HEAL

HFM A2.4 HFM B1.1 HFM B4.3 HFM A2.5 HFM B3.1HFM A2.8 HFM A2.9 HFM B14.2

TO TALK & BE LISTENED TO

HFM 1.2 HFM C2.6HFM 1.4 HFM 6.1

FEEL SAFE

HFM 3.5HFM B16.4HFM C2.4HFM C2.6

BE ABLE TO GO OUT

HFM 3.5 HFM A2.9HFM 3.8 HFM B3.1HFM 6.1 HFM B16.4 HFM C2.4

HELP HERSELF

HFM 1.5 HFM B16.4 HFM C2.4HFM B3.1 HFM C2.1 HFM F4.4HFM B15.8 HFM C2.2

WORRIED ABOUT DYING

HFM 1.5 HFM B18.1HFM B3.1 HFM C2.6HFM B14.2

7 JH/MAY11

FRED’S NEEDS

HELP WITH SONIAHFM 3.8 HFM 6.1 HFM B17HFM B2.2 HFM C2.6 HFM F4.1HFM B4.3 HFM C2.4

MONEY WORRIES

HFM 1.5HFM B16.4HFM C2.4HFM C2.6

TO BE PAIN FREE & ABLE TO BREATHE

HFM A2.4 HFM B1.1 HFM B14.2HFM A2.5 HFM B3.1 HFM B15.1HFM A2.8 HFM B4.3 HFM B15.6HFM A2.9 HFM B15.8

TO TALK & BE LISTENED TO

HFM 1.2 HFM C2.6HFM 1.4 HFM 6.1

FEEL SAFE

HFM 3.5HFM B16.4HFM C2.4HFM C2.6

BE ABLE TO GO OUT

HFM 3.5 HFM A2.9HFM 3.8 HFM B3.1HFM 6.1 HFM B14.2

HELP WITH DOMESTIC WORK

HFM 3.8 HFM B16.4 HFM C2.6HFM 6.1 HFM B17 HFM C2.4HFM A2.4

WORRIED ABOUT SONIA DYING

HFM 1.5 HFM B18.1HFM B3.1 HFM C2.6HFM B4.3 HFM B14.2HFM B18.3

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Fred & Sonia’s Needs Competences

JH/MAY11

PATIENT PROXY HFM SfH REFERENCE FUNCTION SfH COMPETENCE

SONIA & FRED’S NEEDTo talk and be listened to.

CORE 1 COMMUNICATION HFM 1.2 Communicate effectively

CM G4 - Communicate with individuals, groups and communities about promoting their health and wellbeing in adefined caseload

HFM 1.2 Communicate effectively

CHS48 - Communicate significant news to individuals

HFM 1.2 Communicate effectively

GEN62 - Collate and communicate health information to individuals

HFM 1.2 Communicate effectively

GEN97 - Communicate effectively in a healthcare environment

HFM 1.4 Develop relationships with individuals

HSC233 - Relate to and interact with individuals

HFM 1.4 Develop relationships with individuals

CHS100 - Develop relationships with individuals with long term conditions

CORE 6 EQUALITY & DIVERSITY

HFM 6.1 Ensure your own actions support equality of opportunity and diversity

HSC234 - Ensure your own actions support the equality, diversity, rights and responsibilities of individuals

SPECIFIC C HEALTH PROMOTION

C2.6 Act on behalf of an individual, family of community

HSC368 - Present individuals' needs and preferences

C2.6 Act on behalf of an individual, family of community

HSC410 - Advocate with, and on behalf of, individuals, families, carers, groups and communities

Knowsley Care Campus

Data Collection & Analysis; diagnostics

Single Point of AccessReferrer

Entry: Critical Episode Risk Stratification New patient

Step Down From Active

Case Management

Joint Multi Disciplinary

Meeting

Eligible for Active Case Management Allocate to Key worker

Active CaseManagement

Signpost to Other Services; other pathways

P

Discharged

Deceased

GP

Specialist

Practitioners/Nurses

Intermediate

Patient

Care

Third

Sector

Reablement

Family

Carers

Patient Centred Care

Care Co-Ordination

Key Worker; Active Monitoring

Effective Utilisation of Integrated Resources

Promotion of Self Care/

Management

Direct

Care

Step Down

•Transfer to other care pathways

•Self Caring

•No longer risk stratified (return to general practice for routine management

Pathway for Critical Episode

Clinical Triage

STEP 1.

STEP 2. STEP 3.

STEP 4.

STEP 6. STEP 7.

STEP 8.

STEP

5.

STEP 9.

CORE WORKFORCE:

•Assistant Practitioner

•Community Matron

•Community Staff Nurse

•District Nurse

•Health & Social Care Worker

•Re-ablement Worker

•Social Worker10 JH/MAY11

Fred & Sonia’s Care Campus PathwaySTEP 1. Fred phones the single point of access requesting an urgent response to Sonia ‘s deteriorating health.

STEP 2. Urgent referral process set in motion - practitioner contact within 4 hours.

STEP 3. Practitioner reviews Sonia’s existing electronic health records in the community.

Urgent response- practitioner visits within 4 hours to assess and address Sonia’s urgent needs.

STEP 4. Practitioner presents Sonia & Fred’s current health status and needs to MDT meeting – Case Management agreed . STEP 6. Key worker allocated

STEP 7. Active Case Management. Assessment of Sonia & Fred’s needs, intervention, advice, information and review of health & wellbeing.

STEP 8. Step down from active Case Management. Sonia & Fred remain on the District Nurse caseload to address Sonia’s pressure area needs.

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Fred & Sonia’s Care Campus CompetencesPatient’s Perspective/Need

Service Provider

Role/responsibility

Health Functional Map

SfH Reference Function SfH Competence

STEP 1.

Sonia’s health is deteriorating.

She is experiencing increasing pain.

She is unable to sleep.

She is placing increasing demands upon Fred that he cannot address.

Fred is worried about Sonia and wants help for her.

Fred’s health is also deteriorating as he attempts to take care of Sonia.

Fred phones the Care Campus phone line to request an urgent response.

Fred wants to know how long it will take for someone to visit?

STEP 1.

Single point of access (SPOA)

Call received by Admin staff.

Consent sought.

Fred listened to and details documented.

Specific questions asked from script.

Fred reassured and informed that a health practitioner will be with him within 4 hours.

Admin staff confirms that they will phone Fred back to inform him who the health practitioner will be.

Any immediate relevant advice given.

CORE1

COMMUNICATION

SPECIFIC B

HEALTH

INTERVENTIONS

CORE 6

EQUALITY &

DIVERSITY

CORE 1

COMMUNICATION

HFM 1.2

Communicate

effectively

HFM 1.4 Develop

relationships with

individuals

HFM B1.1 Obtain

valid consent for

interventions or

investigations

HFM 6.1 Ensure

your own actions

support equality of

opportunity and

diversity

HFM 1.5

Provide information,

help and guidance

HFM 1.2

Communicate

effectively

GEN97 – Communicate

effectively in a healthcare

environment

GEN21 – Interact with

individuals using

telecommunications

HSC233 - Relate to and

interact with individuals

CHS100 – Develop

relationships with

individuals with long term

conditions

CHS167 - Obtain valid

consent or authorization

HSC234 - Ensure your

own actions support the

equality, diversity, rights

and responsibilities of

individuals

HSC26 - Support

individuals to access and

use information

HSC21 – Communicate

with and complete

records for individuals

C A

R E

C

A M

P U

S

CASE MANAGEMENT

CASE MANAGEMENT

EPISODE OF CARE/INTERVENTION

LONGTERM CONDITIONS POPULATION – SELF & GENERAL PRACTICE MANAGEMENT

Step Up/ Step Down

Trigger points for patients to access appropriate service and support based

on risk factors

RISK STRATIFICATION = HIGH

RISK STRATIFICATION = V. HIGH

Core workforce competences:100HFM 1.2 HFM 4.6 HFM A2.4 HFM B3HFM 1.4 HFM 4.7 HFM A2.5 HFM B14HFM 1.5 HFM 5.1 HFM A2.6 HFM B16HFM 2.1 HFM 5.2 HFM A2.8 HFM C2HFM 2.2 HFM 6.1 HFM A2.9 HFM D2HFM 3.5 HFM A2.1 HFM B1 HFM F4HFM 3.8 HFM A2.3 HFM B2

High level workforce competences: 17HFM A2.2 HFM B16.4HFM A2.3 HFM B17HFM A2.4 HFM B18.1HFM B14.2 HFM B18.3HFM B15.6 HFM C2.5HFM B15.8

Very High level workforce competences: 4Skills for HealthHFM B4.2HFM B4.3HFM B14.1HFM B15.1

KNOWSLEY CARE CAMPUS WORKFORCE

COMPETENCES

CORE WORKFORCE: Assistant practitioner. Community Matron. Community Staff Nurse. District Nurse. Health & Social Care Worker. Re-ablement Worker. Social Worker.

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References

• ODS (2008). Organisation Development Services Population Centric Model for Workforce Planning. ODS

• Skills for Health (2011). Competency Based Planning Tools. SfH