Primary Care Home: The Thanet Way
The Primary Care Home model at Thanet focuses on providing care to a defined population with a personalized approach, integrating various disciplines and aligning financial resources with healthcare needs. Challenges include an aging population, complex health conditions, deprivation, and resource constraints. Various medical practices and services in the area cater to the diverse healthcare requirements, emphasizing the importance of integrated care and community partnerships.
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Primary Care Home - The Thanet Way! Thursday 2nd March 2017 Maria Howdon, Head of Membership Development
Four core characteristics of a Primary Care Home The provision of care to a defined, registered population size of 30,000 to 50,000 people 1 2 A combined focus on personalisation of care with improvements in population health planning, provision and outcomes An integrated, multi-disciplinary workforce, with a strong focus on partnerships spanning primary, community, secondary, third sector, mental health and social care 3 Financial drivers aligned with the health needs of the whole population. 4
Challenges in Thanet. Ageing population More chronic, complex conditions High levels of deprivation Undiagnosed conditions Overstretched resources Workforce shortage Significant growth in housing
The Limes Medical Centre: Dr H McCafferty Dr A Jain Dr A Majeed Dr S Thallam Dr M Vincent Dr R Misra Practice Population: 13,761 Bethesda Medical Centre: Dr Joy Dr Martin Dr Scott Dr Miller Dr Sohail Dr Mohammed Dr Jha Dr Roux Dr Su Dr Karamat Practice Population: 15,913 Westgate Surgery: Dr D Meakin Dr G Jha Dr C Leire Dr B Vishwanathan Dr A Walton Practice Population: 9,959 Union Row Surgery: Closed 28.02.17 List dispersal Garlinge Surgery Branch of Limes Medical Centre 1 Birchington Medical Centre: Dr A Ghazi Dr A C Martin Dr A Tasou Dr E Osman Dr I D Finlay Practice Population: 8,918 Northdown Surgery: Dr J De Murtinho-Braga Ossa Dr J Geevarghese Dr H Williams Dr M Wolny Practice Population: 10,664 Minster Surgery: Dr C Crosfield Dr M Elliott Dr M Jansen Van Vuuren Dr G Stern Dr R Mangam Practice Population: 8,067 Summerhill Surgery: Dr S Grover Dr S Kamal Practice Population: 6,161 Mocketts Wood Surgery: Dr D Reddy Dr D Marshall Dr S Kanumuru Practice Population: 8,469 The Grange Medical Practice Dr J Bonnett Dr J R Johnstone Dr J M Lyell Dr O Lyell Dr M Maiden-Tilsen Dr S L Marsden Dr F Newton Dr M Bannon Practice Population: 11,940 East Cliff Practice Dr C A Neden Dr J Neden Dr C Eldred Dr L Kent Dr A M Macpherson Dr E Mash Dr A Peshen Dr M J Pick Dr M Sivakumar Dr J M Woodward Practice Population: 15,327 St Peters Surgery: Dr A J Cunard Dr S Goldberg Practice Population: 4,543 Newington Road Surgery: Dr A Akyol Dr I Ali Dr N Mohammed Practice Population: 7,864 Dashwood Medical Centre: Dr M Cardwell Dr J Malasi Dr P Wilson Practice Population: 9,438 Broadstairs Medical Practice: Dr A Malik Dr I Ali Dr A Khalid Dr S Qureshi Practice Population: 6,873 Quex Broadstairs Ramsgate Margate
Ramsgate PCH Quex PCH Westbrook House Practices Social Care Practices Social Care Montefiore MC Intg d Workforce Intg d Workforce Mental Health Mental Health Voluntary Sector Outpatient Clinics Outpatient Clinics Voluntary Sector Prevention & self care Prevention Self Care Diagnostic Diagnostic Broadstairs PCH Margate PCH IAR / Acute Interface Practices Social Care Practices Social Care Bethesda MC New Build Intg d Workforce Intg d Workforce Mental Health Mental Health Outpatient Clinics Voluntary Sector Outpatient Clinics Voluntary Sector Prevention Self Care Prevention Self Care Diagnostic Diagnostic
2 Enhanced Frailty Pathway. 1st Pathway Developed Former Over 75 s Schemes Nursing Homes LES End of Life LES Focus on personalisation of care, prevention and wellbeing for the Over 60 s Acute Response Team (ART) Defined metrics and outcomes Integrated workforce Alignment of finances Went live on 1st October 2016 / 14th November 2016 Robust evaluation
3 Integrated Primary Care Joint Nurse Clinics Catheter care Wound Care IV Therapy (PICC Lines) Joint Nurse Home Visits Long term condition management Domiciliary Carers Carers being trained to deliver care to support nursing teams Voluntary sector Care Navigation - Age UK / Ageless Thanet Margate Task Force
4 Capitated Budget. A tool was required to enable correlation of data, across multiple providers in a new way. Working with South Kent Coast CCG and Kent Public Health the Kent Integrated Dataset (KID) was developed and built.
Kent Integrated Dataset Acute Hospitals Social Care Hospice Community Providers Kent Integrated Dataset Thanet District Council Mental Health Providers Fire Service Primary Care Police
Approach to PCH Budget Setting Population stratified by quinary age band (0-4,5-9,10-14 ) Average annual cost; per head of population, in each age band was calculated for EACH and EVERY service (every POD and Speciality combination in every age band). Correlation between deprivation and health costs, particularly non- elective activity. e.g. PCH and practice population costs were calculated by adding up the costs for their cohort of patients.
Thanet Benefits 25k expected annual savings from reduced A&E attendances enabled by Thanet s shared patient care record. Admissions avoided through cross practice working over bank holidays. A&E Attendances 530k approximate annual savings from a reduction of 15 A&E admissions a week following the roll out of the Acute Response Team. A&E Admissions 216k of potential medicine review savings if the pharmacist pilot were carried out across the whole care home population. The average medicine review saving per resident was 165. Prescribing Zero vacancies for community nurses, falling from 24 WTE since PCH go live. Staff Retention Additional EMIS benefits will include reductions in A&E attendances and admissions out of hours, increases in primary care capacity and reduced waits for GP appointments. Additional Savings
