Transforming by Design: New Care Models This guide shares the experience of Hull LHC Demonstrator in

1
Transforming by Design New Care ModelsThis
guide shares the experience of Hull LHC
Demonstrator in designing a new care model for
people with Coronary Heart Disease. The guide
provides a framework for Care Model Development,
giving practical examples of Hulls approach to
each step
A Detailed Guide for the NHS
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Introduction and Context... A comprehensive
review of literature failed to identify a
definitive method for designing care models, or
indeed agreement of definitions between care
models, care pathways and care protocols.
However, if we are to make a fundamental shift in
the way we commission health care services in an
environment of patient choice and market
contestability, commissioners will need to be
clearer in defining what care they wish to
provide for their population, to what standard,
what price and the volume of care needed, taking
into account the pathways of care which
individual people will need to take through the
care model. This guide does not profess to be a
definitive guide, or indeed grounded theory, but
aims to share the experience of Hull LHC
demonstrator in designing a care model for
people with Coronary Heart Disease. Designing
the Care Model for CHD in Hull continues to be
work in progress. If you would like more
information or would like to keep updated on
progress please contact Philip Davis, Head of
Joint Commissioning Public Health Development,
Hull PCT. Philip.davis_at_hullpct.nhs.uk.
About Hull

• The city of Hull is one of the most deprived in
  the country with a SMR for coronary heart disease
  of 30 above the national average.
• Many people in Hull die from CHD because they do
  not access health services at times when they
  need to
• CHD accounts for 22 of all deaths
• In general, the population have low educational
  attainment and low aspirations about their
  health potential
• 50 of the population smoke, 55 do not exercise,
  obesity is in line with the national average,
  binge drinking in young people (particularly
  young women) is problematic
• Hull PCT is a spearhead PCT which is currently
  off track in relation to health inequalities
  targets
• Hull and East Yorkshire Hospitals Trust is a
  secondary and tertiary provider of acute cardiac
  services and the main provider within the
  community Classic hospital is a local private
  provider of services Hull is in the process of
  tendering for a Referral Diagnostic and Treatment
  Service from a private provider
• Reducing death from CHD has been the focus for
  service improvement in Hull for a number of years.

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Why care model design matters

• What do we mean by Care Model Design?
• Care Model design provides commissioners with a
  description of the care it needs to purchase for
  a given population. The description of the care
  model forms the basis of the commissioning
  specification. A robust and detailed
  commissioning specification facilitates the
  delivery of care which is of a high standard, is
  accessible, safe and of value
• It is proposed that a care model contains three
  key components
• Care Elements - The term care elements is used
  to describes what care is needed in terms of
  care interactions (contact between the patient
  and health services) and interventions (actions
  taken with the patient). A description of the
  care elements provides a menu of options for care
  purchased on behalf of the population, which
  patients and clinicians can access together, to
  address individual health needs. Examples of care
  elements include angiography, primary
  assessment, CABG etc
• Care Pathways - Care Pathways define the route
  that different patients need to take through the
  care elements defined in the care model. These
  routes are governed by patient choice, clinical
  need and evidence based practice. The care
  pathway is used to determine the setting in which
  care is to be provided and the competencies
  needed to deliver that care
• Clinical Protocols Clinical protocols are
  agreements reached and documented on what
  diagnostics and treatments will be used at
  different junctures of the care pathway and with
  which types of patients clinical protocols can
  inform the competencies needed to deliver care
  and the identification of quality indicators used
  for the purpose of commissioning care.
  Commissioners may choose not to include clinical
  protocols in their specification, leaving
  providers to determine such protocols.

• Why is care model design important for successful
  service transformation?
• Care models provide a description of the whole
  care journey, which is then used to define
  commissioning specifications for service
  delivery. This provides commissioners with an
  overarching view of the care needed
• Defining care models forms the basis of the
  designing services process within the NHS
  commissioning framework (1)
• Designing care models enables you to develop care
  provision from the patients perspective,
  challenges traditional practice, ensures that
  current practice is based on evidence, improves
  safety, quality and efficiency, and integrates
  workforce, estates, IT, finance and information
  in the process of development
• Local Health Communities are able to define and
  integrate national and local priorities for
  change as principles which underpin care model
  design
• Care model design enables the local health
  community to deliver the benefits it aims to
  achieve for its local community through
  implementation of the model
• Care models help to establish agreed outcome
  measures, so that commissioners can focus on
  outcomes rather than specifying how care is to be
  delivered
• Care model design helps commissioners to
  understand the scope of market provision needed
  to deliver care.

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From our collective experience of developing care
models, we suggest a number of building blocks
which together will lead to the successful
development of a care model. It is important to
note that the order of the building blocks is
less important than the process of development -
discussion, engagement and outputs.
Demonstrator Experience Process for designing
care models
Care Model Scoping
Care Model Design
Define the elements of care provides the menu
of care options available
Which care model should we design?
Who should we involve?
Define the levels of service needed describes
the care pathway
What is the scope of our care model?
Write Commissioning Specification
What are the principles that underpin our care
model design?
Integrate the enablers of change into your design
Process
Technology
What benefits do we want to deliver?
Workforce
Identify outcome based quality performance
indicators
Predict the volume of care we need to purchase
Do we need to redesign all of the care model or
just parts of it?
Identify the price at which you will purchase the
care
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• Deciding which care model to design
• Effective Care Model design takes time and
  engagement from a
• range of stakeholders and support from central
  functions such as
• HR, Finance, Estates etc. There are a number of
  drivers which may
• inform your choice of which care models to focus
  on. These might
• include
• NHS Policy - NHS commissioning guidance (1)
  states that all PCTs should review at least one
  care model a year
• Response to your local strategic needs assessment
  - ISIP RTC strategy and benefits guidance can
  support you with undertaking a strategic needs
  assessment. The RTC strategy and benefits
  guidance (2) helps you to design your vision for
  future health care provision, assess where you
  are now , what your priorities are for the next 3
  5 years and which programmes of work will
  address the gap
• Local and National priorities - such as meeting
  the 18 week target, achieving financial balance
  etc. Ideally these should form part of your
  strategic needs assessment and determination of
  your local priorities for change. However,
  assessment of 18 weeks delivery may lead you to
  define a range of care models which require
  redesign to meet referral to treatment times
  prior to completion of a comprehensive strategic
  needs assessment
• Response to practice based commissioning
  intentions practice based commissioners may
  identify certain care conditions and pathways
  where efficiencies can be made through
  re-provision in primary care.
• Response to changes in clinical practice such
  as NICE recommendations.

• Key Questions
• What is driving your decision of which care model
  to develop?
• How does the care model you are focussing on
  support delivery of the strategic priorities of
  the local health community?

Hull Local Health Community experience Care Model
Development with the Hull Local Health Community
Demonstrator resulted from their strategic needs
assessment and a more detailed health equity
audit on CHD. CHD was shown to be a major cause
of mortality in Hull with 22 of all deaths being
related to heart disease. Plans to build a new
cardiology centre as part of the Hull and East
Yorkshire Hospitals estates strategy, and the
impending development of a new independent
sector referral, assessment, diagnostic and
treatment centre, provides the opportunity to
review and remodel the way CHD care is delivered.
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• Deciding the scope of care model design
• Individual health need takes people on a
  continuum from
• wellness to death (3). A proposed approach to
  defining
• the scope of the care model is based on the
  following
• health care continuum
• Primary Prevention supporting the general
  population to stay well
• Prevention for those at high risk supporting
  those people with identified risk factors which
  may lead to ill health (such as smoking, people
  in certain age bands etc)
• Support for those with ill health symptoms who
  require diagnosis and initial treatment this
  may be either through an acute or scheduled
  health care route
• Ongoing or continuing care for those with a
  health need
• End of Life Care
• Experience tells us that commissioners may focus
  on
• specific aspects of the care continuum when
  designing
• care models, rather than including the whole care
  
• continuum, e.g. support for those with ill
  health
• symptoms. Is often the focus of urgent care
  model
• design.
• Defining which level of the continuum to include
  is often
• determined in response to pressure locally on
  service

• Key Questions
• Which health care continuum levels will you
  include in your care model design?
• Do you need to be mindful of the impact your
  design has on the levels of care you have not
  included?

• Hull Local Health Community experience
• The scope of our CHD project includes
• Prevention of those at high risk of developing
  CHD
• Support for those with ill health symptoms who
  require diagnosis and initial treatment
• Ongoing or continuing care
• The LHC has 2 other projects which focus on
• population based primary prevention and End of
  Life
• Care. These projects cover a broad range of care
• conditions. The CHD project board ensures that
  the
• work we are doing aligns and complements the
• Primary Prevention and End of Life Care projects.

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• Agreeing the principles which underpin care model
  design
• Experience has shown us that Care Model design
• focuses on specific care groups, such as Diabetes
  , or
• care themes such as urgent care. In providing
  health
• services to the population, Local Health
  Communities will
• have a number of strategic objectives that they
  will want
• to achieve.
• Examples of key strategic objectives include
• To provide health care as close to home as
  possible while ensuring safety, high quality and
  efficiency in care delivery
• To maintain financial health across the local
  health economy
• To integrated the use of IT in care processes
• To ensure staff feel valued, safe and supported
  at work and have the skills and competencies to
  deliver safe and effective care
• To make best use of NHS estate.
• These objectives form the principles to be
  considered
• when deciding relevant parts of care model design
  e.g.
• where care needs to be provided, the use of
  technology
• to support care delivery and care processes etc.
• Taking this approach facilitates the delivery of
  the LHC

• Key Questions
• Is the focus of you care model a care group, such
  as ENT, CHD, or a care theme, such as urgent care
  or case management?
• Has your local health community defined their
  strategic objectives? If so..
• How can you deliver these objectives while
  delivering you new model of care?

• Hull Local Health Community Strategic Objectives 
• By 2008, The people of Hull will
• Wait less than 10 weeks from seeing their GP to
  having elective treatment in 80 of cases, with
  the remainder waiting a maximum of 18 week
• Be treated in modern, 21st Century healthcare
  facilities, which are open at a time to suit
  service users.
• Have rapid access to a comprehensive range of
  mental health services
• Have their care delivered by a redesigned
  workforce that is better able to respond to their
  needs than existing professional groups
• Use a single point of access to a
  well-coordinated pathway for unscheduled care
• Use services that are closely integrated with
  those of the voluntary sector and local
  authorities
• Have access to treatment in a variety of centres
  through the Choice programme
• Enjoy responsive services supported by
  well-integrated IT structures to improve
  efficiency and safety
• Be supported in a range of community and
  individual programmes to improve their health
• Have confidence in a responsive healthcare
  system, which operates within its financial
  limits.

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Define the elements of care which make up the
menu of options available to patients and
clinicians defines what care to purchase on
behalf of your population The term care
elements is used to describe what care is
needed in terms of care interactions (contact
between the patient and health services) and
interventions (actions taken with the patient). A
description of the care elements provides a menu
of options for care purchased on behalf of the
population, which together patients and
clinicians can access to address individual
health need. Examples of care elements include
angiography, primary assessment, CABG
etc. Clinicians and front line practitioners are
the best people to define what care they need to
have in their menu of options. The menu is based
on clinical guidelines, clinical evidence and
best practice. The Map of Medicine is an
effective resource which can support clinicians
in defining the elements of care needed within
the menu of options. Commissioners will want to
review recommendations on what to include in the
menu of options and make decisions on which
elements to purchase based on a comprehensive
cost benefit analysis.
Hull Local Health Community Experience The Hull
CHD project includes Cardiologists, a GP, Cardiac
Specialist Nurses, the Acute and Primary Care
Clinical Nurse leads and the clinical lead for
ambulance services. The clinical team have worked
together to define the elements of care required
within the menu of care options (example of which
is below - NB this is not the definitive list).
Hull have used the year of care framework (5)
which recognises the patient as a key partner in
their care this encourages commissioners to
define the self care, care support and clinical
management elements of care provision. The CHD
care model spans the care continuum prevention
of those at high risk to continuing
care.
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Define the levels of service which make up the
care model defines the care pathway In the new
world of health care contestability, aimed at
encouraging new providers to enter the market
place, commissioners may want to avoid defining
care settings in terms of Acute Hospitals, GP
practices etc and consider defining levels of
care services in which the care is to be
provided. Defining care services as part of care
model design helps you to consider how people
access services and the level of skills and
competencies needed to deliver specific aspects
of care. A proposed model of care settings
across a care model is now being utilised in a
number of LHCs and as part of the nationally
agreed 18 week pathways. These include Self
Care Elements of care people provide for
themselves, which may be supported by the
provision of health care information, self help
programmes such as obesity support, aimed at
helping people to self care. First Contact
Services These are often generic services such
as NHS direct, General practice, pharmacies etc.
These providers often have a range of generic
skills across a broad spectrum of care
conditions. Specialist Services Services
focussed on specific care groups or care themes.
Requires detailed knowledge of the management of
specific care conditions/themes (e.g. trauma
care skills). Highly Specialist Services -
Services which provide highly specialist
management of atypical or complex care conditions
/ themes. Typically provided in tertiary
centres. By using techniques such as process
mapping (4) you can map the high level care
pathway that patients will take within you new
care model and link these to the care
elements you have defined. An example map of the
CHD diagnosis to treatment pathway using the care
settings approach can be found below. A larger
version is available at the end of this document.
Hull Local Health Community experience It took us
some time to think about levels of service for
people with CHD rather than thinking in the
traditional way of GP practice etc. People with
Heart Disease are more likely to use traditional
health settings when experiencing symptoms and
when requiring diagnostics and treatment due to
the potential impact of the condition. However,
we wanted to test out the use of levels of
service to inform future service improvement
work with other care conditions.
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Some thoughts on key roles involved in the design
of care models...
Care Models that lead to the delivery of services
which are safe and provide both quality and
value, can only be developed when all parties
involved in the delivery and management of care,
work together throughout the design process. You
may want to consider the following key roles......
Leadership is the key to success... Experience
shows us that using robust programme and project
management approaches when developing care models
leads to success. Strong leadership from
commissioners is essential.
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• Do we need to redesign the whole of the care
  model or just parts of it?
• Having decided which care model you want to
  design, it is
• helpful to
• review how that care is currently provided
• whether the way care is currently delivered meets
  the needs of the population
• if there may be better ways in which care
  provision could be enhanced.
• This will show you which parts of the care model
  requires
• redesign.
• Some commissioners may choose to only specify
  those parts
• of the care model which they have changed within
  the
• commissioning specification, and contract for
  those services
• which do not require redesign using the existing
  contractual
• route.

Hull Local Health Community Experience Hull LHCD
have been developing CHD services for a number of
years. They used the ISIP step 2 process
(Strategy and Benefits Planning) to take stock of
progress and agree what other improvements would
help them to achieve their planned benefits of
reducing health inequalities and reducing death
from CHD. Service developments identified through
the strategic analysis was complimented by a
desire from the consultant cardiologist clinical
lead and GP CHD clinical lead to achieve better
outcomes for their population, by improving the
quality and timing of referral to treatment for
those people with an identified cardiac symptom
this led to the work package we have called 18
weeks. Assessment of current state forms a key
part of the ISIP approach. We have found tools
such as the diabetes commissioning tool kit (7)
useful in providing a framework for reviewing
current service information.

Predicting the volume of care we need to
purchase Capacity and demand modelling techniques
have been widely implemented in the NHS for a
number of years. However, traditionally demand
for services has been calculated by looking at
the previous years activity and adding a certain
percentage for increased demand. Some LHCs are
starting to explore the use of prevalence data
alongside demand modelling to estimate the volume
of care commissioners may want to purchase on
behalf of the local population. There are a
number of tools available that can help with
predicting the volume of care to be purchased
e.g. The NDST commissioning tool kit (7).
Hull Local Health Community Experience Hull are
aiming to use a mixture of prevalence data taken
from the health equity audit, current demand and
estimates of the percentage of patients who
require certain elements of care determined by
clinicians. We will model the predicted volume of
care through the new care pathway and test our
assumptions within our care model pilots. We are
proposing that focused attention on primary
prevention and prevention for those at high risk,
should reduce demand on the initial assessment
and treatment care continuum within our care
model. This is work in progress.
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Integrating the enablers of change in care model
design...Delivery of the care model requires the
use of key resources such as workforce, estates,
technology and information. Tools used for
process redesign, workforce tools such as agenda
for change, role redesign and new technology are
known as enablers of change if considered as
part of care model design, these enablers can
help to derive both quality and value as an
integral part of care model design.

• Best practice processes....
• Good practice processes that you have identified
  and
• tested during care model development can be
  expressed
• as quality indicators within your commissioning
• specification
• Some questions you might want to consider....
• Have you identified processes that add value?
  map care processes, eliminate waste, check for
  risks and holes in the system, use the principles
  which underpin your care model to define value
  (see NHS Institute website for process mapping
  tools)
• Keep the flow moving are activities piling
  up? Avoid batching processes, plan to do today's
  work today! Use capacity and demand modelling to
  help you (see NHS Institute no delays achiever
  for capacity and demand tools)
• Move to a pull system rather than push can
  you pull people into the next part of the system
  rather than waiting for a queue to form?
• Have you referred to clinical evidence to inform
  the sequencing of care processes within your care
  model e.g. do you need to perform one set of
  diagnostics or procedures prior to a second set?
• Test new processes during the course of
  developing your model of care to see what works
  in your local environment (See Hull LHC 18 week
  case study).

• What IT is available to you?
• Express IT requirements in your commissioning
  specification
• - you made need to represent IT in stages if the
  packages and
• systems are not yet in place.
• Some questions you might want to consider....
• What does you local NPfIT implementation strategy
  say?
• Have you engaged with your IT team to advise on
  the use of IT?
• What kit is available and where? If your model of
  care involves services delivered outside the
  traditional setting, think about what your IT
  needs would be e.g. PACS to view images, image
  capture systems, Choose and Book
• Are you using Choose and Book to pull referrals
  through the system rather than let queues build?
• Are your clinicians using tool such as Map of
  Medicine to develop and/or review care pathways?
• What level of IT skills exist within your LHC? Do
  you need to link with your training department if
  improvement is needed?
• Do you have an information sharing protocol in
  place between NHS providers and the Local
  Authority?
• What systems or data base will you use to monitor
  progress and performance of care model delivery?
• What information can you provide to patients and
  front line staff, and can you provide that
  information to patients and front line staff
  electronically?
• Have you agreed minimum requirements for the use
  of IT and data standards needed to deliver the
  care model?
• Have you thought about whether there are any
  mandatory reporting requirements that must be met
  from your model of care what will be required
  and how will you capture, collect, store and
  report/submit it?

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Thinking about the workforce needed to deliver
the care model....

• ..the role of Health Care Commissioners and
  Providers in workforce change?

• Design and specify the model of care designed
  around service users
• May specify key workforce functions and
  competencies needed to deliver the service model
  but not roles i.e. care coordination but not care
  coordinator)
• Specify workforce (employment) quality indicators.

Commissioners

• Decide what roles and numbers are needed to
  deliver service model
• Will need to provide evidence of effective staff
  deployment, management and development (people
  governance).

Providers
Hull Local Health Community experience We have
two focused workforce based developments as part
of our project. The first is the introduction of
the role of patient coordinator The coordinator
pulls patients through our 18 week pilot
pathway. The post holder was previously a band 3
Medical Secretary and is now a band 4
coordinator. Personal contact with patients has
contributed to the achievement of no DNAs out
of the 90 people we have had through the
pilot! The second work package is the review of
the cardiac specialist nurses across acute and
primary care. Our aim is to target the specialist
skills of this team to patients with greatest
need, moving the team from a predominantly
rehabilitation role to a case management role,
which will act as a bridge across primary and
secondary care.

• Some questions you may want to consider....
• Have you reviewed the roles of people who deliver
  the care model and thought about new ways of
  working and/or new roles?
• Are there any training and development
  requirements?
• Have you connected with your HR specialists to
  advise of employment law, workforce planning and
  workforce design?
• Have you linked the workforce changes needed to
  the overall workforce plan for the LHC?
• Have you agreed the workforce quality indicators
  you would expect providers to meet?
• Have you expressed workforce competencies and
  functions within your commissioning
  specification?
• Have you include workforce quality indicators in
  your commissioning specification?

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• Identifying outcome focussed quality and
  performance indicators
• The description of the care model will be used to
  develop the detailed
• service specification which commissioners will
  use to purchase care
• from a range of providers. The expression of
  outcome focussed quality
• and performance indicators have a number of
  roles
• Help commissioners to express the quality of the
  service they wish to purchase
• Provide a clear indication of how service
  delivery will be assessed
• Provide providers with a clear description of
  standards to be achieved.
• There are a number of quality indicators already
  expressed within the
• national service contract for Foundation
  Hospitals and the SLA
• framework for non foundation providers. It is
  prudent to build on these
• rather than duplicate them, focussing on specific
  quality and
• performance indicators, which are sensitive to
  your local population and
• care groups health need.

Hull Local Health Community experience We are in
the very early stages of thinking about what
outcome focussed quality and performance
indicators we will include in our commissioning
specification for CHD . As we develop the pathway
through our care model, we have been thinking
about and recording what tells us this activity
provides quality and how can we measure that
quality. We will review this information along
side national clinical standards which should
result in the definitive key indicators for use
in our commissioning specification.

• Identifying the Price of the care to be
  commissioned
• The national tariff provides a framework for
  determining the price to be paid
• for elements of service delivery. However, not
  all new service provision is
• covered by tariff and in the world of
  contestability, some providers may
• choose to deliver care at less than tariff price.
• It is helpful to consider a number of activities
  which guide decisions on the
• price of care. These include
• Assessing the cost of delivering elements of
  the care model
• Understanding the total budget of the existing
  care model delivery - the use of programme
  budgeting methods help with this
• Understanding of what additional resources may be
  available to respond to business cases for
  increased resource aimed at delivering increased
  benefit resulting from implementation of the care
  model.
• Engaging your finance colleagues in the redesign
  process will help them to
• understand the scale and scope of the care model
  which will allow more
• accurate financial assessment.

• Hull Local Health Community experience
• We are yet to determine the price of care
  delivery for use in our commissioning
  specification. However, we have completed a
  number of activities which will help us to
  understand what the price may look like. This
  includes
• Development of a programme budget for CHD (as
  part of the programme budget pilot scheme)
• Modelling of cost benefits for the healthy
  hearts work package.

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• Putting it all together What will Care Model
  Design provide you with?
• A description of what care needs to be provided
  including self care, clinical management and care
  support requirements presented as a menu of care
  elements
• A picture of the level of services required to
  deliver the care model, which will facilitate
  soft market analysis of potential providers and
  the analysis of risks and benefits of providing
  the model in different ways
• A description of minimum IT/information
  requirements
• Description of Workforce functions and
  competencies (NB but not numbers of people and
  roles this is the business of providers)
• The quality indicators expressed as outcomes that
  providers must meet includes requirements for
  clinical governance, health and safety, infection
  prevention and control, best practice process,
  workforce quality etc
• The performance metrics with associated measures,
  which will demonstrate that the model of care is
  provided in line with requirements and how
  national and local objectives are to be met
• The ceiling price you will pay for each element
  or part of the care model and/or the totality of
  the care model
• The predicated volume of care you wish to
  purchase.
• This information can then be pulled together to
  form your commissioning specification/(s)

We hope you have found this guide helpful. We are
continuing on our journey of developing the
process of care model design which will culminate
in the development and implementation of patient
centred commissioning specifications. We invite
you to add to this body of knowledge which will
help us to update this guide and share experience
with others. If you would like to comment on or
contribute to the development of this guide.
Please email Danielle Procter. Danielle.procter_at_nt
lworld.com
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Experience of Care Model Development Hull Local
Health Community

• Our situation....
• The city of Hull is one of the most deprived in
  the country with a SMR for coronary heart disease
  of 30 above the national average
• Many people in Hull die from CHD because they do
  not access health services at times when they
  need to
• CHD accounts for 22 of all deaths
• In general, the population have low aspirations
  about their health potential
• 50 of the population smoke, 55 do not exercise,
  obesity is in line with the national average,
  binge drinking in young people (particularly
  young women) is problematic
• Hull PCT is a spearhead PCT
• Hull and East Yorkshire Hospitals Trust is a
  secondary and tertiary provider of acute cardiac
  services and the main provider within the
  community Classic hospital is a local private
  provider of services Hull is in the process of
  securing a RDTS from a private provider.

• What we did....
• Established robust project management structures
  to govern our work
• Engaged clinical champions from acute and primary
  care to work in partnership with commissioners to
  develop the model of care
• Linked priorities relating to urgent care,
  scheduled care and LTC into our care model
  development as CHD sits across all of these
• Worked closely with the cardiac network to
  support us, challenge our thinking and provide
  additional expertise
• Used information collected as part of the Hull
  CHD health equity audit to understand what health
  inequalities exist and ensure we built this into
  our care model
• Have begun to develop the year of care model to
  inform how and what we will commission ensuring
  self care is a strong element of our work
• Established key work streams - 18 week pilot,
  Review of specialist nurse roles, urgent access,
  healthy hearts scheme.

• What we have achieved...
• Secured strong clinical engagement
• The year of care model has been drafted
• 18 week pilot in place and outcomes being
  measured at 4 weekly intervals
• Specialist nursing service review has taken place
• Healthy hearts scheme commissioned through
  locally enhanced service contracts.

• What will we do next?
• Develop our commissioning
• Specification by describing the
• care model
• Calculate the volume of care we
• need to purchase
• Complete of work on urgent access
• Plan for roll out of 18 week pilot
• Explore remaining elements of 18 week pathway and
  make improvements
• Develop the specification for self care support.

17
Care Model Design

• Year of Care (YoC) model
• Three key components
• Self Care
• Care Support
• Clinical Management

Our aim is to include prevention and self care
along the entire pathway
Stratification of patients links to clinical
protocols about care management
Can we use the YoC model to predict how much
care we need to purchase in the future?
18
The Scope of the care model
The Service Menu Describes the Care Elements
care model
The levels of service defines care settings and
care pathway
The year of care domains
19
Healthy Hearts Service

• Targeted health screening of practice population
• Those with Life Style issues signposted to life
  style advice
• Those at high risk of CHD receive appropriate
  course of treatment and placed on practice
  disease register
• Commissioned through a Locally Enhanced Service
  framework

Costings quantified on how much Practice
Nurse time would be needed to deliver the scheme
Developed a pilot to test how this scheme would
work in practice
Practices value 11 support with GP clinical lead
and Commissioner to discuss implementation of
the scheme in their practice
20
18 week pathway

• Redesign of pathway from referral to treatment
• Development of referral criteria to speed up
  treatment and reduce duplication
• Compact with patient to agree treatment options
• One stop approach to first outpatient appointment
• Pull people through the system role of patient
  coordinator
• Case management and rehabilitation redesign of
  specialist nurse roles
• Timely feedback and management plan to GP

Specialist CHD Nurses are present at the first
outpatient appointment and case manage patients
with ongoing CHD needs
Patient coordinator receives the booking advise
note via Choose and Book, contacts the patient to
pull them through the system
21
Hull CHD 18 Week Pathway
22
Where to go for more information

• Useful links/References
• Commissioning guidance www.dh.gov.uk/en/publicati
  onsandstatistics/publications/publicationsPolicyAn
  dGuidance/DH_413
• Better Commissioning Network http//www.icn.csip.
  org.uk/index.cfm?pid5
• 18 week Commissioning Pathways
  http//www.18weeks.nhs.uk/public/default.aspx?load
  ArticleViewerArticleId645
• Workforce Planning tools http//www.healthcarewor
  kforce.nhs.uk/resources/latest_resources/six_steps
  _e-learning_resource.html
• Competency Frameworks http//www.skillsforhealth.
  org.uk/page/competences/completed-competences-proj
  ects
• ISIP Roadmap for Transformational Change
  http//www.isip.nhs.uk/roadmap
• ODonnell M (1986) Definition of Health
  Promotion. American Journal of Health Promotion.
  Summer 1986, Vol.1. No.1 p4.

Lead Author Danielle Procter NHS Integrated
Service Improvement Programme Contributors Alan
Nobbs NEYNEL Cardiac Network Manager Phil
Davis Head of Joint Commissioning Public
Health Development, Hull PCT Helen Rea NHS
Integrated Service Improvement Programme Stephanie
Reid NHS Integrated Service Improvement
Programme Andrew Prince NHS Integrated Service
Improvement Programme Andrew Waring NHS
Integrated Service Improvement Programme