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Table 1 TIDieR Checklist description of the demonstrator pilot sites

From: Implementing new care models: learning from the Greater Manchester demonstrator pilot experience

Item number Item
1 BRIEF NAME
Site A: Pro-active case management for care home residents
2 WHY
High ambulance and GP callouts to care homes; too many non-elective admissions to hospital; Care home residents having long lengths of stay in hospital; lack of access to clinical (GP) records from care homes.
Goals: to improve access to clinical care outside hospital, specifically reducing GP and ambulance call-outs, hospital attendances and admissions, to facilitate integrated records and allow direct patient access to these.
3
4
WHAT
Pro-active case management for adult residents, most aged 65+, of five care homes, registered with one of three general practices in one CCG area. Risk-stratifying care home residents and providing enhanced care planning, including end of life and crisis planning, using risk stratification.
Procedure: Care home residents were risk stratified, using the model previously employed in Greater Lever. For each, the case manager, carried out an initial, face-to-face holistic assessment and put a care plan in place, which was recorded on the GP system using a template.
At the start of the demonstrator the case manager had access to general practice records via a computer in her office, partway through the demonstrator, she acquired direct read-write access to the records via a laptop. After the initial assessment, the case manager would manage patients using a video conferencing facility.
Materials: General practices involved used EMISa, Visiona and TPPa, laptop provided to the case manager.
5 WHO
The service was provided by an advanced nurse practitioner (ANP) who worked during the demonstrator as a case manager (seconded from an acute trust), with input from care home carers and managers, GPs, practice managers and other administrative staff, a CCG pharmacist and members of the local Mental Health Trust’s dementia team. CCG and CSU project managers and the integrated care lead (from the local Foundation Trust) also contributed.
6 HOW
An initial face to face assessment, followed by case management of patients using a video conferencing facility, with the ANP ‘ringing in’ to run through the residents on her caseload with care home staff, hearing about any changes and performing consultations with patients, where necessary.
7 WHERE
The assessments and consultations took place in care homes, additional work was undertaken in general practices.
8 WHEN AND HOW MUCH
Each care home resident had one initial assessment and then consultations were performed as required.
9 TAILORING
Individual assessments were undertaken and care plans produced for each care home resident receiving case management.
10 MODIFICATIONS
In practice, the video conferencing technology was not used for both technical and organisational reasons. Rather, the care home staff contacted the ANP by telephone, to discuss residents or to ask her to visit the home. Notably, when at a home, the ANP was often asked, by care home staff, to respond to acute problems for residents that were not on her caseload.
Item number Item
1 BRIEF NAME
Site B: Additional availability appointments
2 WHY
Difficulty for patients in obtaining timely and convenient access to general practice; too many emergency hospital admissions.
Goals: To improve access to care, specifically providing quicker and more convenient access to routine primary care, reducing attendances at A&E.
3
4
WHAT
Additional availability appointments for registered patients of five practices in a township plus one other three miles away, (c. 33,000)
Procedure: Additional availability appointments were provided by two GPs, working 6.30 pm to 8 pm Monday to Friday and 8 am to 6 pm at weekends. Three of the practices involved were housed within a purpose - built primary care centre; two of these practices and the practice located outside Radcliffe were owned by the same GP partner. Most appointments were pre-booked, with six kept as emergency appointments for allocation after 6 pm. From 6 pm the practice phone lines diverted to A Healthier Radcliffe.
Materials: The appointment booking system was hosted at one practice and the other five logged into this to book appointments. All six practices used Vision with access to the full record, allowed through a data sharing agreement on a read-write basis. GPs used a smartcard to log into each practice system.
5 WHO
Two GPs and receptionists.
6 HOW
Face to face appointments.
7 WHERE
GP practices.
8 WHEN AND HOW MUCH
Patients booked appointments as required. Each appointment was 10 min in length, 18 appointments per day were provided Monday –Friday and 12 per day Saturday and Sunday.
9 TAILORING
N/A
10 MODIFICATIONS
N/A
Item number Item
1 BRIEF NAME
Site C: Additional availability appointments; responsiveness appointments; homelessness service; extension of specialist advice lines
2 WHY
Some patients being unable to access timely GP appointments; patients with long term conditions not having timely access to a healthcare professional; insufficient healthcare provision for homeless people.
Goals: To improve access to care, specifically reducing A&E attendances, by providing urgent same day (responsiveness) and additional availability appointments in general practice. To improve specialist primary care services and reduce secondary care planned activity, by shifting specialist service provision from secondary to primary care.
3 WHAT
1. Additional availability appointments (33/35 practices).
Procedure: Additional availability appointments were provided at four ‘host’ practices. The additional availability appointments were provided by 1 GP at each site, between 6 pm and 8 pm Monday to Friday, and 9 am to 11 am at weekends. The participating practices across the CCG area and A&E at the local acute trust booked appointments at the host practice, which were available on a quota basis, until 1 pm and then made available on a first come first served basis.
Materials: Practices logged into the host practice’s system. All practices ran EMIS, either EMIS web or as streaming practices with access to the full record, allowed through a data sharing agreement, on a read-only basis.
4 2. Responsiveness appointments (31/35 practices);
Procedure: Practices fitted the responsiveness appointments within the regular working hours of the practice. For example, one practice allocated four telephone triage slots and four appointments to the on – call doctor and two appointments each to all other doctors (the number of doctors in the practice varied).
Materials: a macro was put onto each practice system and used to log the outcome of appointment.
3. Homelessness service (1 practice);
Procedure: provided under a Locally Enhanced Service arrangement, run at a practice with a large local homeless population (often transient). A health questionnaire for patients was completed, to ascertain health needs and then the patient was signposted to various services (clinics for dressings, immunisations, substance misuse services), several of which operated from the same premises as the practice.
4. Extension of specialist advice lines;
Procedure: The ‘specialist advice lines’ were a facility for GPs to get advice from hospital consultants. The service was pre-existing and the additional specialities were added as part of the demonstrator.
Materials: Advice lines operated through a dedicated email address for GPs to use.
5 WHO
The additional availability appointments were provided by 1 GP at each site, supported by two reception staff, Lead organisation was a GP federation; some additional availability appointments were staffed by locum GPs; the A&E department could refer into the additional availability appointments, local voluntary services could refer into the homelessness service. Hospital consultants staffed the advice lines.
6 HOW
Appointments took place face to face and via the telephone.
7 WHERE
GP practices.
8 WHEN AND HOW MUCH
Patients booked appointments as required. Each additional availability appointment was 10 min in length, 12 appointments per day were provided Monday-Sunday.
9 TAILORING
N/A
10 MODIFICATIONS
Some changes to the original timings and booking arrangements were made. The weekday additional availability appointments were originally offered entirely on a quota basis and the weekend appointments continued until 12 pm. It appeared some GPs ended up seeing the patient again in normal surgery hours after the additional availability appointment, because they were unsure about what had happened at the appointment. Some practices did not participate in providing the responsiveness appointments; Reasons for non - participation included a lack of capacity in the practice for responsiveness, concerns around IG for one practice and proximity, and being situated on the CCG geographical border.
Item number Item
1 BRIEF NAME
Site D: Additional availability appointments; GP-led care planning; multi-skilled care worker led care planning; hospital navigator service
2 WHY
Too much demand on general practice; ‘inappropriate’ use of A&E for problems that could be handled in general practice; A&E used by frail elderly that resulted in avoidable admissions; increase in A&E attendances from 1 pm onwards (when practices are open).
Goals: To develop integrated care in line with the CCG strategy. To improve access to care, specifically access to general practice, reduced A&E attendances and hospital admissions. To improve care of the frail elderly through care planning. To develop the IT infrastructure, specifically to allow hub clinicians to access patients’ records, allow practices and patients to book appointments at the hub (a GP practice), and let practices know when their patients are in hospital.
3 WHAT
1. Additional availability appointments for patients registered with GPs in one locality.
Procedure: A hub was set up to provide additional GP and nurse appointments, with three nurse clinics and three GP sessions each day. GPs provided additional appointments 4 pm to 9 pm on weekdays and 10 am to 8 pm at weekends. Practices ran the appointment bookings until 6 pm, after which time patients could phone and book directly. The acute trust provided a late-night path lab collection.
Materials: Four practices used EMIS, two used Vision. Host practice accessed summary care record on Adastra* on a read-only basis.
2. Care planning
Procedure: GPs produced care plans for their frailest elderly patients. The multi-skilled care worker visited patients aged 85 and over at home to identify and assess their needs and produce a care plan.
4 3. Navigator service
Procedure: The navigator kept track of presentations to one local A&E department, focussing particularly on those aged 65 and over, so tended to see patients with confusion, falls, and long term conditions, particularly multiple sclerosis and chronic obstructive pulmonary disease. She assessed each patient (each
patient was also assessed by the medical team and had tests done as appropriate). Where patients were medically fit and did not need to be admitted, the navigator took responsibility for ensuring that the relevant support was in place, either in the form of a placement, if they were not safe to return home, or home support services (e.g. from team providing crisis response).
5 WHO
The project lead was a GP. Local out of hours provider (supplied GPs and receptionists for additional availability appointments); the navigator was an occupational therapist based at a local general hospital, the multi-skilled care worker was based at a foundation trust.
6 HOW
See ‘procedure’ for a description of how each component operated.
7 WHERE
Additional availability appointments took place in person, at GP practices, care planning took places in GP practices and at patients’ homes, the navigator service operated in hospital.
8 WHEN AND HOW MUCH
Patients booked appointments as required. Each additional availability appointment was 15 min in length, 28 appointments per day were provided Monday-Friday, 51 on Saturday and 24 on Sunday.
9 TAILORING
Care plans were prepared for individual patients. The navigator service arranged tailored care packages for patients.
10 MODIFICATIONS
The additional availability GP appointments were typically booked, but the nursing ones were less popular and were replaced with GP appointments after six weeks. Issues arose as practices which had been allocated appointments were unwilling to give up their allocated slots to other practices which had filled theirs.
Item number Item
1 BRIEF NAME
Site E: Additional availability appointments; mental health crisis clinics.
2 WHY
Too much demand on general practice; lack of an accessible mental health service locally.
Goals: To improve access to care, specifically providing quicker and more convenient access to routine primary care, reducing attendances at A&E and increasing access to mental health services, by extending access to routine primary care and providing additional mental health services in the community.
To make better use of local resources and support the local population to do this, specifically to reduce attendances at A&E, reduce hospital admissions and facilitate quicker discharge from hospital, by providing signposting and education to local services in the community, improving patient pathways and supporting collaboration between professionals in different agencies.
3 WHAT
1. Additional availability appointments for patients registered with GPs in one locality.
Procedure: The general practice additional availability appointments ran from the lead practice. A purposely developed Care Diary was used by GPs, the local out of hours provider and A&E staff to book patients into the additional availability appointments. Patients were triaged at A&E and, if the ailment could be managed in the community, they could be booked into a GP or nurse appointment by staff at A&E using the Care Diary.
Materials: six practices used EMIS, two used Vision. EMIS practices were able to share records on a read-only basis, Vision practices were not able to access records. Since Dec 2014 all practices have been EMIS web allowing all to share records on a read-only basis.
4 2. Mental health crisis clinics for patients registered with GPs in one locality.
Procedure: The clinics were organised by a trained counsellor, who co-ordinated the service and provided appointments, plus other counsellors (and trainees) who also worked at another local general practice. Appointments were provided between 6.30 pm and 9.30 pm, Monday to Friday.
5 WHO
The project lead was a GP. The additional availability appointments were provided to registered patients, at the lead practice, by GPs, supported by receptionists, all supplied by the local Out of Hours provider. The mental health appointments were provided by trained counsellors and counselling students. The demonstrator appointed a dedicated project manager partway through. CSU and EMIS also contributed to the project.
6 HOW
See ‘procedure’ for a description of how each component operated.
7 WHERE
In person, at GP practices,
8 WHEN AND HOW MUCH
Patients booked appointments as required. The additional availability appointments were each 10 min in length and 18 appointments were provided per day, Monday-Sunday. The mental health appointments were each one hour in length and three per day were provided, Monday- Friday.
9 TAILORING
10 MODIFICATIONS
The additional availability GP appointments were typically booked, but the nursing ones were less popular. Issues arose as practices which had been allocated appointments were unwilling to give up their allocated slots to other practices which had filled theirs. Some local GP practices did not refer patients to the mental health appointments, the lead GP was aware of this but the reasons for non-engagement are not known.
Item number Item
1 BRIEF NAME
Site F: Rapid response step-up service; complex care service; enhanced end of life service; carer needs assessment service; mental health liaison, care homes; end of life training, care homes and locality.
2 WHY
Too many non-elective hospital admissions; too many patients dying in hospital; district nurses were under pressure and did not have enough time to provide the right end of life care and support to patients and carers.
Goals: To proactively identify and manage people with complex needs via a core integrated team that can draw on specialist support when necessary. To support people with heart failure by extending telehealth services. Support for people to be maintained in their own home or care home where this is their preferred place prior to and including death. A reduction in unplanned, avoidable non-elective activity prior to and including death.
3 WHAT
Overall: The demonstrator was part of the restructuring across health and social care, through the development of an ‘integrated hub’ in each CCG locality. The demonstrator took place in one locality, where the first hub had been established. The hub premises accommodated social workers and third sector staff. Stockport had shared patient information via the Stockport Health record which enabled GPs, secondary care and Out of Hours services to access each other’s systems. An extension of the Stockport Health Record, to include health and social care data and integrated care plans, was planned to support the implementation of the Stockport One Integrated Care Team and was further developed within the demonstrator community demonstrator to ensure that the whole range of services within the hub had appropriate access to information. In terms of specific systems operating locally, social care used CareFirst, district nurses used DominiC, the REaCH service used Staffplan, and domiciliary workers users used CM2000 (to log each visit).
4 1. Rapid response step-up service provided to people aged 18 and over.
Procedure: GPs referred into the service via a dedicated number at a contact centre when they felt a patient did not need to go to hospital, but needed support putting rapidly in place. Once the GP had made the referral, the patient received a response within 2 h from a team comprising a district nurse and a social worker. The patient could be maintained in their own home or go into a step-up bed. This service ran from 9 am to 5 pm and the intermediate care service provided an Out of Hours service.
Materials: six practices used EMIS, two used Vision. EMIS practices were able to share records on a read-only basis, Vision practices were not able to access records. Since Dec 2014 all practices have been EMIS web allowing all to share records on a read-only basis.
2. Complex care service
Procedure: the population was risk stratified. Multidisciplinary teams (MDTs), involving a GP and a practice nurse, worked to agree an integrated pathway and model of care for individual patients. The work undertaken followed the same basis as the GP care plans which had already been developed, but allowed other healthcare professionals to contribute to these. The task of coordinating the care plan was undertaken by various professionals (GPs, district nurses, social workers) and also voluntary sector workers. The multidisciplinary group (MDG) was a wider network of professionals which operated at a more strategic level, looking across the locality and identifying, for example, high rates of chronic obstructive pulmonary disease and considering what action should be taken, rather than necessarily focussing only on patients within the high risk stratification.
Materials: the People at Risk of Readmission tool was used for risk stratification
3. End of life care service
Procedure: The end of life care service was newly designed service that focussed on integrating health and social care. This is a jointly delivered service between district nursing (health) and assistant practitioners (social care) in the community. The service delivers end of life care to people in the last weeks and days of life undertaking joint assessments, care planning and visiting the person in their home to deliver interventions that meet the needs of the patient and their carers or family.
The health and wellbeing service was planned as an extension of the existing service, into a different area. The end of life training consisted of delivering a module to care home staff. The dementia-focussed training consisted of several one-hour training sessions delivered to care home staff.
Materials: End of life training based on the Six Steps programme and providing follow up telephone support.
4. The mental health liaison in-reach service involved working with three care homes to provide advice and support, particularly care planning.
5 WHO
The demonstrator was part of a programme of work developed by the CCG and local authority, a hub was established and a hub co-ordinator was employed; the local Foundation Trust, Community mental health trust and local authority reablement service were involved; Project managers and general practice staff contributed. The MDT and MDGs were comprised of GPs, district nurses, social workers, primary care pharmacist and third sector staff. The end of life service was provided by assistant practitioners (domiciliary workers) from the REaCH service. The end of life training for care homes was provided by end of life facilitators. The health and wellbeing service was led by project managers, liaising with general practice staff. The carer assessments were carried out in general practice, with input from GPs and administrative staff. The mental health liaison in-reach service was provided by a community psychiatric nurse and a support worker.
6 HOW
All services were provided in person.
7 WHERE
At GP practices, in patients’ homes, in step-up facilities, care homes.
8 WHEN AND HOW MUCH
Services were provided to patients as required.
9 TAILORING
10 MODIFICATIONS
The aim was for district nurses to be co-located at the hub but this was not possible within the timeframes associated with the demonstrator. In practice, social workers were ‘paperless’ whilst district nurses used paper records.
  1. acomputer systems used in general practices and/or the companies that supply these systems