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CHEADLE & BRAMHALL NEIGHBOURHOOD

ENGAGEMENT SESSION

29 September 2015

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Outcomes

• Update on the progress made to deliver 7 day working across the neighbourhoods and locality

• Share a case study around 7 day working• Share progress on the complex care pathway• Agree how GPs will support the Integrated Team 8-8 in the

interim• Discuss and agree how neighbourhoods will manage urgent

patients on the day• Update from Viaduct, including progress with the draft MoU

for a Cheadle, Gatley & Heald Green and Bramhall and Cheadle Hulme.

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Neighbourhood Evening Events• Opportunity to hear about the outcomes of the workshops and detailed

designs – how will it be different?• Frequently Asked Questions & Q&A session• Meet your Neighbourhood Team

Cheadle Neighbourhood Monday 5th October 6.30pm – 8pm with Indian meal

Cinnamon Tree, 224 Finney Ln, Heald Green SK8 3QA

Bramhall Neighbourhood Wednesday 7th October 6.30pm – 8pm with Turkish and Mediterranean food

Turquoise, 65 High Street, Cheadle SK8 1BJ

All members of the neighbourhood team welcome, to book your place please email maureen.burke@stockport.gov.uk by 30th September

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Final C&B Neighbourhood meeting

• Thursday 15th October• 1.30 – 4.30 pm• Stockport County, Hardcastle St, Edgeley

• Prevention & Screening• Pull together previous sessions into working model

Complex care pathway

• Taken all the feedback from the previous workshops, spoken to people outside the workshops

• Formed into a Standard Operating Procedure by Project Manager

• Will be shared in full at the evening events next week for final tweaks

• One decision for GPs to make……

Seeking consensus

• GP input into the actual GP meetings• Options

1) One GP to asked to give input into all the MDTs and develop plans. Will allow for some consistency but GP will have no knowledge of most of patients

2) Individual GPs phone or Skype into MDT to discuss their own patients

3) Try option 1 in one neighbourhood and option 2 in one neighbourhood

SOP_Process_Map_(V0.1)

6. The Process

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Step down and managed by appropriate local services

GP Practice Risk Stratification Meeting

Led by Practice with support of Advanced Nurse Practitioner

can attend if GP wishes)

Decision on management plan determined by criteria.

For GP and/or Integrated Team Care (low risk/green), for referral to MDT (medium/amber to high/red risk)

Part of Integrated Neighbourhood service

Retained in Practice/IT

Part of MDT Administrator for collection of individual’s information

Integrated Neighbourhood MDT meeting

Outcomes - Case Management Plan

Identify Case Manager Development of Preventative Plan,

Crisis Plan, Management plan and Signposting

Feedback to GP (if designated GP assigned), by documentation to be sent or Advanced Practitioner

to attend next risk stratification meeting

Agreement and review of Case Management Plan

Active Case Management Plan sent uploaded on to Stockport Health & Care Record involved

Integrated Team (IT)Triage Meeting

Led by Neighbourhood Team Leaders

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Conversation 2Neighbourhood management of urgent patients

• Is there an opportunity to use the neighbourhoods to better manage acute demand or urgent patients presenting to primary care?

• How can we use the neighbourhoods to better manage patients presenting to the integrated team with crisis?

• What else does the neighbourhood need to achieve this?