Delivering System Wide Patient Centred Co-odrinated Care TODAY

Introduction: Cumbria/North Lancashire has established a resource matching/e-referral system in our major provider organisations (currently 1800+ e-referrals/month) across all health and care, independent and 3rd sector stakeholders.

In addition, we are engaging cross border e-referrals for Cumbrian patients accessing specialised services in the North East/ Newcastle Hospitals FT.

This system-wide co-ordinated care provides full transparency and accountability throughout each patient’s journey and optimises care outcomes whilst ensuring optimal resource utilisation.

Aims/Objectives:

1- Adult  health and care electronic booking of residential and nursing care beds from independent sector;

2- Health and well-being and Integrated Care Community e-referrals to health and well-being hubs/sector services;

3- e-referrals for Assessment, Discharge and Withdrawal notices from health organisations to adult social care, in accordance with  the Care Act 2014, Schedule 3;

4- e-referrals to adult safeguarding;

5- acute/hospital e-referrals to community hospitals/community based services;

6- Continuing Health Care, fast track,checklist, DST and Panel process automation

7- GP e-referrals to emergency, acute, community,  and CountyCouncil services, (aligned with NHS eRS for elective);

Method/Rational: 

1. NHSE Safety Patient Alert–the handover of patients is a complicated and multi factorial process. Communication is identified as a particular area of risk and accounted for 33% of 10000 incidents reported to NRLS. Review of these incidents indicated that patients are sometimes discharged without adequate/timely communication of essential information to relevant staff/teams. 

2.Success Regime-January 2016 Deloitte’s report

Our population is super-ageing, with a higher than average growth in the proportion of older people

High levels of ill-health prevalence rates; we have a high treatment burden in primary/secondary care.

Geography makes service delivery harder than average–communities spread over large distances; isolation a key factor.

Key services (urgent /emergency care, secondary care diagnosis /treatment and rehabilitation) are not always provided sufficiently promptly; core access standards are not consistently met – this is especially the case for people who are frail/need multi agency care

Results/Conclusions: Citizens/patients–Enhanced patient safety from reduction in time spent in hospital e.g. reduced risk of medication errors, dehydration, under nutrition, hospital acquired infections; improved timeliness of transition across services

Supported social prescribing referrals via GPs to commissioned health/well being services; voluntary sector services.

Streamlined referral processes into Adult Safeguarding using electronic forms

Health and care providers – improved shared data quality; standardised demographic and relevant clinical data; improved communication; transparency of progress of e-referrals to support proactive management of care pathways and minimise blockages.

Industry-collaboration between suppliers of EPR’s to link with the e-referral system and provide standardised interfaces that enable health/care staff to optimise the use of a real time DOS-dynamic interoperability.

Academic / research- totally new data sets emerge.

Commissioners – ability to see a comprehensive directory of services and load balance resources.

Health and Wellbeing/ASC commissioning strategies forStaff – reduction in wasted time/effort from paper and fax; ability to devote time to positive action to support patient care. 

Enhanced patient choice in long term care / compassionate care placements.

Enhanced patient outcomes via clearer, well suited patient journey to appropriate care settings

Estimated £400,000 efficiency savings annually thus far*NHS England IDCR report