New Models of Care – The Symphony Programme, South

Case study summary

The Symphony Programme created a new model of care with an emphasis on person centred, coordinated prevention. Creating team environments where patients will be supported across the team and not simply by registered clinical staff (GPs and nurses). Health coaches and keyworkers are trained to provide relevant and focused support for clinicians and patients.

 

The south Somerset NHS vanguard site – The Symphony Programme created a new model of care with an emphasis on person centred, coordinated prevention. The team, consisting of non-registered workforce (health coaches and keyworkers) will work alongside primary and secondary care to support and coach people with long term conditions (LTCs). Creating team environments where patients will be supported across the team and not simply by registered clinical staff (GPs and nurses). Health coaches and keyworkers are trained to provide relevant and focused support for clinicians and patients.

This new model of care with non-registered staff using health coaching approaches, can change health behaviours and support increased patient activation. Those with greater activation make more appropriate use of health services. In addition, this team has the time and skill set to work more closely with patients to understand what may be triggering their health problems or leading them to be poorly engaged with their own health.

Solution

There is an established pattern of 10 minute appointments with clinical staff in primary care irrespective of clinical need. The Symphony Programme will address this by introducing a better and more appropriate skill mix to the practices across south Somerset. Non-registered staff have been introduced and trained in health coaching techniques and skilled in supporting and signposting individuals to the most appropriate services. Patients who are identified (using the symphony scale and clinician/team input) are discussed at team meetings (huddles) that involve clinical, admin staff and non-registered staff. Huddles typically happen daily, or twice weekly and involve as many team members as possible.  Hospital data is made available to the teams in real time via the Primary Conect App, which shows admissions and attendances at the local district hospital.  The team use this information, their EMIS systems and huddle sheets to facilitate their discussions. Actions from these meetings are distributed throughout the team to ensure that the most appropriate team member supports the patient. Health coaches proactively work with the most complex patients supported by their clinical colleagues to ensure that teams  increase activation and effectively care for the whole health needs of each patient.

There are a number of strategies that were employed to ensure that this large scale project delivered the desired results. Such as:

  • Supporting practices to deliver the model by funding and offering resources (money, people and tools)
  • Creating job descriptions and facilitating the recruitment process
  • Designing and facilitating training, not just for the health coaches and keyworkers but for all staff so that the model can be embedded
  • Creating action learning sets and a web based support forum and joint working tool (Jive), which supports development and communication across a wide rural area
  • Facilitating regular meetings for practice managers and supporting health coaches to come together for sharing and discussion
  • A shadowing system for new recruits
  • A lengthy blueprint document has been prepared to ensure that the model and systems that deliver it are able to be rolled out to other areas if needed
  • Comprehensive involvement of patients and carers in developing the model of care to ensure and understand how best to meet their needs
  • The launch of the Esther Champion model, which will see team members champion the patient voice and connect healthcare teams with patients in their environment and not just clinical settings. This model will ensure that quality improvement is embedded across the area – training will be provided to Esther champions to ensure they fully understand and can lead the QI process.

There are a number of introductions and changes that were employed. Such as:

  • Introduction of Jive, a communication and collaboration web tool that opens up shared working and communications to all of the teams that are involved in the project across the whole of south Somerset
  • Introduction of non-registered staff
  • Introduction of team huddles within primary care to facilitate better teamworking and identification of high risk patients
  • Design and delivery of a scoring tool that helps to inform GPs and primary care teams of high risk complex patients (the Symphony score)
  • Design and build of EMIS templates to ensure we are accurately recording interactions of Health Coaches and Keyworkers from all teams
  • Design of reports that can be run to collect data from EMIS and then share this with our ‘soon to be released’ data dashboards
  • Implementation of effective meeting structures so all stakeholders have a voice in the project. We run six different meetings (within a hierarchy to ensure good governance).
  • Build of a complex care clinical notes/data system (Symphony notes)
  • Build of a primary Conect Application to support sharing hospital data with the wider primary care teams
  • Introduction of a ‘hot onboarding’ process that identifies high risk patients within the hospital environment that may benefit from more extensive support from our complex care team
  • Training in health coaching techniques is available for all staff across primary and complex care including health coaches, keyworkers, practice nurses, GPs, practice managers, health care assistants.

Outcomes

The Symphony programme had more than 3,500 patients receiving support from health coaches across south Somerset since September 2015, along with more than 330 patients who have consented to be  being cared for by the complex care team, all of which are reducing the burden on primary care and most importantly are delivering real change in the way healthcare is delivered across the region. Early analysis shows that patients within the complex care service are having reduced admissions, however the launch of the first phase of data dashboards will present a wider range of data from both primary and secondary care.

The programme teams have been diligent in recording how the model is designed and have prepared a wide range of documentation that supports it. The programme team is confident that the detailed blueprint and new model team knowledge would enable them to support other areas of the country to roll out the new care models.

One of the GPs said “I have no doubt that they have reduced admissions and referral failures. They have improved working life for all at the surgery. I have gained an hour a day at least, in addition to some sanity!”

The model started out as two tiers of service, a complex care hub for the most complex and enhanced primary care. However, through working with the practices the programme has identified a need for a second tier of service where teams of specialist GPs and care coordinators (nurses) will work as a flexible supportive resource for practices when required. Once this new second tier of support is established they hope that many more complex patients will be able to receive the new care models via their own GP practices. They will however maintain a central complex care hub for the most complex patients so GPs can continue to refer to the hub.

Tips for adoption

Yeovil District Hospital has developed a detailed kick off processes/presentations and a blueprint for the new models.

For more information please contact

Lisa Pyrke
Communications and Engagement Manager
Symphony Integrated Healthcare

Mobile: 07500 977168
Website: www.symphonyintegratedhealthcare.com
Twitter: @SymphonyProj