Enhancing Care Continuity with Microteams

Continuity of Care Microteams Guide v1.0 - work in progress!

Types of microteams Practices in the One Care project are testing microteams as a way to deliver continuity of care despite having challenges of part time GPs, portfolio GPs, lack of GP team stability and high use of locums. Microteams may offer a patient the opportunity to see GPs they know. In Bristol a group of practice colleagues have considered how microteams could work and proposed there were several forms a microteam could take: i. GP Responsible Lead with supporting GP Buddy ii. GP Responsible Lead with 2 supporting GP Buddies iii. Personalised Microteams including wider multi-disciplinary team and potentially administrative team

Microteams getting started Decision on Team Format and if working with whole practice list or patient cohort Using the Usual GP Tool identify and agree Usual GP & Buddy Preparation Decide how the Microteam will function? How will information be shared, who is in each team? Using the Usual GP Tool data review patient distribution across the teams Team Function Communicate with Staff and Patients what is happening. Map out the changes to move from current ways of working to new ways of working. Conduct a short patient and staff survey to capture views pre and post the change. Preparation Make the changes made to processes. Keep a log of what happens. Use prompts and templates available in EMIS to help support microteam approach. Implementation Review at end of first day, first week and first month to iron out any issues as they arise. At 3 months review quantitative and qualitative data and decide if change is positive Review

Informational continuity is key CAPTURE Agree what and where information will be stored eg last consultation, medication so it can be found quickly and easily. You may find a template useful so you know where to look and to help standardise data collection. CONVEY Endeavour to convey key information about the patient. For example, how a patient likes to receive information eg do they like all the detail, prefer it written down, or like to do own research. REVIEW & TEST A study by St Leonard s practice in Exeter found important family history was often missing or incorrect. For example, father died from heart attack aged 45 years. CARAT Data quality is key, ensure data captured is CARAT (complete, accurate, relevant, accessible and timely). SHARING Agree how the team will share information consider both the usual day to day and also when member of team is on leave. .

Team Members working together Team members need to: - be able to work together - cover the working week - complement each other s skills - understand one another ways of working For a practice this may be the development of existing informal buddying systems. It is also the Gold Standard framework for palliative care where more than one GP is named by the patient.

Continuity of Care Project Manager: Continuity of Care Project Manager: Julia.Martineau@onecare.org.uk Julia.Martineau@onecare.org.uk