HSJ Awards 2014: Managing Long Term Conditions

Bridgewater Community Healthcare Trust: Integrated neighbourhood teams in Wigan

The judges said: “Hats off to a whole system change driving whole person care.”

The creation of integrated neighbourhood teams has helped produce more than 1,000 case management plans for the highest risk patients at Wigan’s practices since April last year.

This has significantly contributed to a 43 per cent drop in A&E visits and a fall of 48 per cent in emergency admissions. Outpatient attendance was down by 17 per cent by January this year.

The highest risk patients are identified using a purpose built risk stratification tool at monthly meetings across all practices, covering a population of 300,000.

Clusters of practices – known as integrated neighbourhood teams – meet to discuss patients referred to them and to agree how they can best be supported to remain independent. Case management plans set out patient goals and the multi-agency, multi-disciplinary staff to support them.

The swift impact of the introduction of the teams can be attributed to factors including solid engagement and GP leadership; the total control offered by an in-house risk stratification tool; and strong governance and project management.

A standard operating procedure; dedicated clinical facilitators and admin support; investment in new technology; patient meetings to agree care goals; and the overall simplicity of the system were other measures behind the success.

Other finalists’ programmes:

• Devon Partnership Trust & Westbank – Neighbourhood health watch
• Alzheimer’s Society – Alzheimer’s Society Merton dementia hub
• Aylesbury Vale Clinical Commissioning Group – Live well
• Bath and North East Somerset Clinical Commissioning Group – Heart failure pathway and passport
• East Leicestershire and Rutland CCG, NHS Leicester CCG and NHS West Leicestershire CCG – Transforming diabetes services: a new model of care for Leicester, Leicestershire and Rutland
• Erewash Clinical Commissioning Group – Welcome home to integrated care
• Lewisham and Greenwich Trust and Lewisham Clinical Commissioning Group – Delivering an integrated interface care model to support patients with long term conditions, to manage their own medicines
• North East London Foundation Trust – Integration: the continuation of an illusion or reality
• The Royal Liverpool and Broadgreen University Hospitals Trust – Diabetes emergency app
• Your Healthcare and Staywell (formally Age Concern Kingston) with Royal Borough of Kingston CCG and Royal Borough of Kingston Adult Social Care – Kingston at Home: integrated care for better health