The Atlas of Shared Learning

Case study

My Care My Way – mapping the older person’s pathway

Leading change

Frontline nurses from across North Tyneside have played a leading role in developing and implementing a new pathway for older people across health and social care  – working with the NHS North Tyneside Clinical Commissioning Group’s (CCG) Transformation and Change Team, to deliver real benefits for both patients and staff. The nursing team demonstrated that by involving service users at the design phase and working closer together to make challenging decisions, they were able to deliver more responsive services that offer high quality person-centred care that maximises health and wellbeing and demonstrates better use of resources.

Where to look

Nurses were heavily involved in service reviews across primary, community, acute and independent care, which identified unwarranted variation in the local pathway for older people. This was backed up by patient feedback. A report produced jointly by the North Tyneside Clinical Commissioning Group (CCG), North Tyneside Council and Northumbria NHS Foundation Trust, identified potential areas to increase efficiencies across the older person’s pathway. As a result, the North Tyneside Health and Wellbeing Board and North Tyneside Integration Board commissioned a detailed mapping exercise of the care pathway.

What to change

The mapping exercise took more than 12 months, involving 42 services, multiple providers and more than 800 patients, carers and staff – including many nurses. The result was a ‘Tube map’ diagram which graphically demonstrated the complexities of the existing care system.

Nurses and others identified a lack of co-ordination across IT systems, organisations and care delivery. Staff lacked training and resources, they expressed that there were clashes of working cultures and felt that there was excessive bureaucracy. The pathway for older people was too complicated, creating barriers and inefficiencies affecting both patients and staff.

The North Tyneside Health and Social Care Integration Programme focusses on the following aims:

  • ensuring that health and social care work more effectively together – through better sharing of information so people only need to explain their problems once;
  • intervening early so that older and disabled people can stay healthy and independent at home – avoiding unnecessary hospital admissions and reducing A&E visits;
  • delivering care that is centred on the individual needs – social care and NHS staff working together, with families and carers, to ensure people can leave hospital as soon as they’re ready;
  • provision of integrated support to carers.

How to change

Nurses, other care staff and patients took part in a number of events to develop a more effective pathway. The work was carried out in four phases:

  1. What is – the current situation and experience
  2. What could be – opportunities for improvement
  3. Co-production – a ‘bottom up’ approach to service re-design
  4. Sustainability – ensuring viability.

The nurses and other participants identified key factors for improvement, including: hearing the patient/carer voice, an integrated workforce and IT, a single point of access and 24-hour availability of resources.

Frontline nursing staff across organisations and services have been at the forefront of developing and applying the new pathway. They continue to lead on the ongoing work across health and social care.

The project has contributed substantially to the introduction of new integrated services:

  • North Tyneside Care Plus: bringing health care professionals, social care and voluntary services together to improve health and wellbeing.
  • Care Point: a first point of access to ensure right care, first time.
  • North Tyneside Intermediate Care – providing short-term care and re-ablement in people’s homes or using ‘step-down’ beds.

Adding value

Nurses and colleagues have felt both engaged and empowered to make successful systemic changes which have achieved better outcomes for patients and an improved sense of wellbeing for staff.

  • Better outcomes – The mapping of the pathway improved communication across wards to streamline patient care. For example, on one ward, before the change, they were admitting and discharging patients, working across a number of different services. Historically this complexity caused a number of difficulties in the patient pathway, delays and increased paperwork. The staff worked together to streamline process and the improvements to address the unwarranted variations and inefficiencies. The resulting improvements in terms of meeting patients’ needs have been replicated in other areas of the organisation.
  • Better experience – The new patient-centred services have improved the experience of both staff and service users. For example, patients are not waiting as long for hospital assessments.
  • Better use of resources – Hospital stays have reduced. In a 6 month period, bed occupancy fell from an average of 38.25 (83.15%) filled beds to 27.8 (77.22%). Patient flows have improved and there are fewer delayed discharges. In particular, the revised care pathway is eradicating wasteful processes, duplication and bottlenecks.

This is still regarded as a baseline outcome, with work now continuing to improve and streamline the pathway, now that it has been fully mapped.

Challenges and lessons learnt for implementation

  • The project was made possible by early endorsement from all organisations at the very highest level. This instilled confidence and provided a mandate to press ahead.
  • Larger facilitated events supported the pathway mapping process – starting with individual teams, who then shared their results with colleagues, patients and carers. This allowed all participants to understand the complex issues affecting others. False assumptions and tensions between organisations were eradicated and an inclusive unified approach was created.
  • A key learning point was the power of collaboration. Front line staff were able to highlight issues and then to lead on designing solutions.

Find out more

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