Cardiff East Cluster

Transcription

1 Network Action Plan Annex 3 Cardiff East Completed by Dr R Morris with help from cluster. 1

2 The Network 1 Development Domain supports GP Practices to work to collaborate to: Underst local health needs priorities. Develop an agreed Network Action Plan linked to elements of the individual Practice Development Plans. Work with to improve the coordination of care the integration of health social care. Work with local communities networks to reduce health inequalities. The Network Action Plan should be a simple, dynamic document. The Network Action Plan should include: - Objectives that can be delivered independently by the network to improve patient care to ensure the sustainability modernisation of services. Objectives for delivery through hip working Issues for discussion with the Health Board each objective there should be specific, measureable actions with a clear timescale for delivery. Action Plans should compliment individual Practice Development Plans, tackling issues that cannot be managed at an individual practice level or challenges that can be more effectively efficiently delivered through collaborative action. This approach should support greater consistency of service provision improved quality of care, whilst more effectively managing the impact of increasing dem set against financial workforce challenges. The action plan may be grouped according to a number of strategic aims. Strategic Aim 1: To underst the needs of the population served by the Network 1 A GP cluster network is defined as a cluster or group of GP within the Local Health Board s area of operation as previously designated for QOF QP purposes 2

3 No Objective Key completi on 1.1 Diabetes Patients, Health Board (HB), diabetes consultants, diabetes specialist nurses 1.2 Heart failure Patients, Primary secondary care Started ongoing care by increasing diabetes specialist nurses (DSN) specialist advice diagnostic echocardiogram Develop protocol for management of HF in primary care. Progress to date negotiations for extra DSN; little progress again in 2016 Started enhanced primary management review. Discussion with secondary care re improved heart failure specialist Started e.advice for cardiology. 1.3 Dementia Patients, Alzheimers Society, Age Concern, care & repair, neighbourhood watch, Secondary care, primary care. UHB priority. Started ongoing Local care improved improved working with third sector. Community cardiology clinic should be starting in 2016 Implementati on of enhanced dementia review achieved embedded. Dementia afternoon held in. Much improved working with third sector. Continued funding of enhanced 3

4 1.3 Obesity Patients, primary care, MEND 1.4 Teenage pregnancy 1.8 Pulmonary rehabilitation Patients under primary care Primary care respiratory dept of secondary care Local mend services Every practice has contraception services including long acting reversible contraception, IUS etc The cluster is trying to set up a local community pulmonary rehabilitation course which would be more accessible to in our area dementia review in Cardiff east local access to mend services Every practice has contraception services including long acting reversible contraception, IUS etc Local community pulmonary rehab course has been successfully implemented is up running in Rumney Smoking Patient s, primary care; Stop Smoking Wales appointm ents referrals We have now set up an electronic referral system which is working well Up running Strategic Aim 2: To ensure the sustainability of core GP services access arrangements that meet the reasonable needs of local No Objective Key 2.1 Access to e.advice, cardiology dept IT dept Pilot completed Easier more timely specialist advice Progress to Date advice up running for cardiology, paeds, rheumatolog 4

5 2.2 Access to named clinician 2.3 Make efficient use of GP time 2.4 Free up GP time by reducing amount of time spent reviewing with mild/modera te depression anxiety 2.5 Employ local pharmacist to add new medications to medication chart after discharge from hospital 2.6 records when GP on house calls continuity for which improves satisfaction outcomes Practices More face to face time with Practices. CPN Practices. Local pharmacist March pilot March pilot GP. Access to skilled CPN to improve strategies to cope with mild/mod mental illness Reduced Gp time spent adding new medication. Practices quality of record keeping health care reduced wasted time by GP y gastroenter ology. Named clinician achieved in cluster for heart failure dementia Examples BP monitor in waiting room Minor illness nurse clinic INR software Planning discussion phase Pilot running in 2 Practice 5

6 Strategic Aim 3: Planned Care- to ensure that needs are met through prudent care pathways, facilitating rapid, accurate diagnosis management minimising waste harms No Objective Key 3.1 The cluster follow agreed pathways including diabetes, heart failure, COPD 3.2 see entries for dementia heart failure. 3.3 diagnosis of hypertension using 24hr Ambulatory BP machines Dec 2015 Optimise management of chronic conditions diagnosis of Hypertension using 24hr ambulatory BP machines in each cluster practice, bought using cluster money Progress to Date Pathways have been adopted by All to buy 24hr ABPM by Dec Most have their machine s are using them but there has been a frustratin g delay in purchasi ng the machine s through the Health 6

7 3.4 diagnosis of skin lesions reduced referrals March 2016 diagnosis of skin lesions reduced referrals by using dermoscope in each practice tele-dermatology. Board procure ment process All to have dermosco pe teledermatolo gy by March 2017 Strategic Aim 4: To provide high quality, consistent care for presenting with urgent care needs to support the continuous development of services to improve patient experience, coordination of care the effectiveness of risk management No Objective Key 4.1 The cluster follow agreed pathways including atrial fibrillation COPD exacerbation Optimise management of urgent care conditions Progress to Date Pathways have been adopted by cluster Strategic Aim 5: Improving the delivery of end of life care No Objective Key 5.1 Adopt end of life care pathway, palliative care team, District nurse team Optimise management of end of life care Progress to Date End of life care pathway has been adopted by cluster 7

8 Strategic Aim 6 : Targeting the prevention early detection No Objective Key 6 Improve early detection of cancers 6.2 Review of new cancer diagnoses Outcome for Improve early detection of cancers improve mortality Improve early detection of cancers improve mortality Strategic Aim 7: Minimising the risk of poly-pharmacy Progress to Date Educational meeting achieved, Practices will review recent NICE guidance review all new diagnoses of cancer No Objective 7 Minimising the risk of polypharmacy Key Minimising the risk of polypharmacy Progress to Date perform regular polypharmacy reviews. has employed a full time pharmacist who is helping with polypharmacy reviews Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance No Objective 8. Complete primary care clinical Key Improve process of care within the practice Progress to Date amber 8

9 governance toolkit Strategic Aim 9: Other Locality issues No Objective 9.1 Reduce inequalities in health. The priorities include Smoking Alcohol Obesity Heart disease Diabetes COPD Key Public health Welsh government Health board Outcome for?? Reduced morbidity mortality in our cluster Progress to Date. Several meetings red 9.2 Electronic transfer of prescriptions from GP to pharmacy Practices Welsh government?? efficiency Reduced None. Too complicated to progress. Red 9

10 Pharmacists workload for GP 9.2 Improve integration joint working with 3 rd sector Practices. Communities first local 3 rd sector agencies Sept 2016 More time for GPpatient. health; improved excellent 3 rd sector projects eg exercise groups, breakfast clubs etc. Mapping of local services. Social prescription up running but not yet used to its full potential 10