Dudley CCG 2 November 2017
- Evaluation of a series of schemes to support development of the Multi-Speciality Community Provider (MCP) model of care in Dudley. The report describes the need, implementation and effectiveness of each scheme.
- The schemes evaluated as "very effective" were:
- Integrated Plus. This scheme embeds locality link officers in MDTs who link patients in the top 2% of those at high risk of hospital admissions and frequent visits to GPs, with community and voluntary services, addressing non-clinical needs through ‘social prescribing’ support. Savings of around £18,000 were reported as resulting from
- A 24% reduction in visits to the GP.
- A 15% reduction in GP home visits.
- A 15% increase in GP telephone consultations.
- A 4% reduction in A&E attendances, saving around £5,000 (522 patient referrals).
- A 7% reduction in emergency admissions, saving around £80,000 (441 patient referrals).
- Falls and Fracture Prevention Service. The redesign expanded the existing Public Health commissioned service to include clinical input: two additional nurses, a physiotherapist and a part-time falls specialist pharmacist and establishment of the single point of access. Early outcome data shows the reduction in waiting times for acute, consultant led falls services falling from 18 weeks to 12 since April. Anecdotally this reduction was supported by interviewees who talked about consultant ability to see urgent cases.
- Practice Based Pharmacists. An extension of an existing service through development of the pharmacist role and standardised contracts. Evaluation indicates savings in repeat medication prescriptions, reduction of waste, avoided hospital admissions and reduction of GP workload.
- Prescription Ordering Direct Contact Centre to standardise and streamline the management of repeat prescribing across Dudley and reduce waste. Based on an existing service the Dudley service. The evaluation showed a reduction in prescription volume, and reduced pressure in associated GP practices.
- Other schemes were:
- Care Coordinator Service - to provide a link within, and between MDTs, and between primary care and hospital services.
- Sense.ly Kiosk - a self-service ‘kiosk’ which enables patients to take their own weight and blood pressure measurements prior to a primary care appointment with guidance by a virtual nurse avatar.
- Sense.ly Patient Services App - combines an electronic triage service with an appointment booking service.
- Care Home Telemedicine Service - supporting care home staff to help prevent admissions to hospital
- Care Home End of Life Education Programme - training and support for care home staff in caring for older people with end-of-life and palliative care needs.
