Key changes from 2015/16
- Minor changes have been made to clarify the timeframe for care plan reviews.
The aims of the ES in 2016/17 is to provide more personalised support to patients most at risk of unplanned admission, readmission and A&E attendance.
From 1 April 2016. Practices must sign up to this service no later than 30 June 2016.
The ES covers five areas listed below
- Practices must provide timely telephone access via an ex-directory or by-pass number for ambulance staff and A&E clinicians to support decisions about hospital transfer and admissions for patients on their list. This number will need to be provided to commissioners.
- An ex-directory or by-pass number should also be provided to care homes and nursing homes, encouraging them to contact the practice before they call an ambulance (if appropriate).
- The practice must provide timely telephone access to other care providers, such as mental health and social care.
- Patients on the case management register should be provided with a same day telephone consultation if they have an urgent clinical enquiry and follow-up arrangements if required.
Proactive case management and personalised care planning
- The practice should use an appropriate risk stratification tool ‘or alternative method’ to identify vulnerable older people, high-risk patients and patients needing end-of-life care who are at risk of unplanned admission to hospital. This should give equal consideration to physical and mental health.
- The practice should establish a case management register of those patients at risk of unplanned admission without proactive case management – this should be at least 2% of the practice’s registered adult patient list (aged 18 and over), which will be calculated on 1 April 2016 and 1 October 2016. Practices must ensure that over the year the register covers at least 2% of the adult population or payments can be reclaimed.
- Any children (under 17) with complex physical or mental health and care needs should be considered for the register.
- The practice should review the register every month to consider actions needed to prevent unplanned admissions.
- Patients on the register from last year do not need to be informed of their named GP again unless there have been changes. Any patient added to the register should be informed within 21 days.
- All patients on the register should receive proactive case management. This includes developing a written personalised care plan jointly owned by the patient/carer and the practice. This should be shared with the wider healthcare team if the patient agrees.
- The plan should aim to improve the quality and co-ordination of care the patient receives. It should also identify the patient’s wishes for the future, if appropriate, and give permission for the practice to speak directly to a nominated carer. The plan must be reviewed at agreed regular intervals with the patient and their carer (if appropriate).
- Patients on the case management register from 2015/16 will need at least one care review, including a review of their plan, during 2015/16. This must be within 12 months of their original care plan or previous care plan review.
- The named GP is responsible for creating the personalised care plan and appointing a care co-ordinator. They are also accountable for ensuring the plan is delivered and reviewed as necessary, even if this review is being conducted by a member of the wider multidisciplinary team.
- The care co-ordinator for the patient (appointed by the named accountable GP, unless they take this role themselves) will act as the main point of contact for the patient. They are responsible for overseeing care for the patient and ensuring that the care plan is delivered.
Reviewing and improving hospital discharge
- When a patient on the register or newly identified as vulnerable is discharged from hospital, the practice, or community staff, must contact them within 3 days to ensure co-ordination and delivery of care.
- The practice will share any action points identified as part of this process with their area teams and if appropriate their CCG to help inform commissioning decisions.
Internal practice review
- The practice will regularly review emergency admissions and A&E attendances of patients from care and nursing homes to understand why they have happened and whether they could have been avoided.
- The reviews should consider whether improvements can be made to processes in care and nursing homes, community services or the GP practice, or whether any individual care plan needs to be reviewed.
- Practices with a large proportion of patients in care and nursing homes should focus their reviews on any emerging themes from a sample of patients.
- Practices should undertake monthly reviews of all unplanned admissions and readmissions and A&E attendances of patients on the register to identify factors within and outside the practice’s control that could have avoided the admission/attendance.
Practices should complete a reporting template twice in the year, no later than the 31 October 2016 and 30 April 2017 respectively. The national reporting template can be found in Annex A of the service specification - linked to below.
Practices may be required to particupate in peer reviews relating to their implementation of this ES. This would only apply where there were concerns about performance and the LMC would be involved.
Read codes to use
|Read v2||Read CTV3|
|Admission avoidance care started
|Informing patient of named accountable GP||67DJ.||Xab9D
|Patient allocated named accountable GP
|Admission avoidance care plan agreed
|Admission avoidance care plan declined
|Review of admission avoidance care plan
|Review of admission avoidance care plan declined
|Admission avoidance care ended
|Emergency hospital admission||8H2..%
The total funding for this ES is £162 million.
Payments will be based on a maximum of £2.87 per registered patient. The practice’s registered population will be counted as at 1 April 2015.
Payment will be made in three components.
- Component 1 – an upfront payment of 46% of the total value of the ES for the practice (£1.33 per registered patient).
- Component 2 – a mid-year payment of 27%, payable no later than 30 November 2016 (77p per registered patient).
- Component 3 – year end payment of 27%, payable no later than 31 May 2017 (77p per registered patient).
Components 2 and 3 are subject to achieving:
- Maintaining the register at a minimum of 2 per cent of the practice’s adult patient list. Practices must have a minimum of 1.8% of patients on the register at 30 September 2016 as a proportion of the list size on 1 April 2016 for the component two payment and 1.8% of patients on the register on 31 March 2017 as a proportion of the list size taken on 1 October 2016 for the component three payment.
- Identifying the named accountable GP and care coordinator for patients on the register – and informing new patients of this.
- Developing personalised care plans for new patients on the register and undertaking at least one care review in the past 12 months for existing patients on the register
- Implementing or continuing a same day telephone consultations for patients on the register.
- Using the practice’s ex-directory/by-pass number.
- Reviewing and improving hospital discharge processes for patients.
- Undertaking regular reviews of emergency admissions and A&E attendances.
Payment will be triggered on the basis a practice has 1.8% of patients on the register at the dates specified above, who have been informed of their named accountable GP and who have had their care plan developed or reviewed in the last 12 months. This will be determined from manually submitted data via CQRS and automated data collections when GPES is available.
Commissioners will also check that same day telephone numbers, bypass numbers, hospital discharge process, practice reviews and the patient survey (if used) have been delivered.
- View the full service specification for this ES here, including reporting templates
- A template letter to inform patients of their enrolment onto the ES and a template leaflet explaining the ES can be found in the 2016/17 GMS contract guidance