HOW IT WORKS
The Dudley Vanguard program is designed as a patient-focused model for delivering integrated care to people most at risk of emergency hospital admissions. This new model of care, the multispecialty community provider, is based on a network of multidisciplinary teams (MDT). These “teams without walls” are led by a general practitioner (GP) and include specialist nurses, social workers, mental health providers, and voluntary sector staff. The teams identify the top two percent of patients who lack a care plan and are at risk of an emergency hospital admission, and then meet weekly or monthly to discuss patients’ clinical needs and develop care plans. The GP takes a leadership role in such activities as drug reconciliation, medication management, care transition planning, ongoing review of care plans, monitoring overall patient outcomes, and structuring MDT meetings. Care transition planning supports the transition to primary care after hospital discharge. Referrals to the program can be informal. The program routinely collects data on activities and patients are tracked though a data system.
This program was initially implemented in five GP practices as test sites, then replicated and rolled out to all 46 practices in Dudley’s five localities. The program has stable funding and has been evaluated by an external research study.
GPs chair the MDT meetings and are largely responsible for patient intake. GPs are involved in carrying out health assessments. A trained staff care navigator screens for mental health needs and carries out assessments for patients with social needs. Providers in the program include nurses, social workers, pharmacists, and secondary specialist care. Rounds (patient review meetings) support integrated care.
The program encourages patient independence, engagement, and self-management. Patients and caregivers provide input on developing individualized care plans, based on shared decision-making. The program maps options for social support and provides patients with help accessing social services. The program is committed to caregiver support and coaching.
The initial MDT implementation group (now called the integrated community team group) comprised all heads of services, from district nurses to mental health providers. Chaired by the director of organizational development, it is overseen by a board composed of the chief executives of partner organization members.
SUPPORTIVE POLICIES: While MDTs exist in other programs across the country, this program differs in how it wraps teams in a hospital setting around primary care, linking primary care with community services. That link is the most successful aspect of the program. The main difference in the staffing model is in how staff work with primary care providers. They do not have to undertake any additional training and are empowered within their current roles.