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8 June 2011 Integrated Care Pilot Launch event. 1 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel.

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Presentation on theme: "8 June 2011 Integrated Care Pilot Launch event. 1 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel."— Presentation transcript:

1 8 June 2011 Integrated Care Pilot Launch event

2 1 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

3 2 Prof. Elisabeth Paice Chair, Integrated Management Board

4 3 Improve quality of patient care Create a richer professional experience Efficient use of NHS funds Integrated care can deliver benefits for patients, clinicians and the wider health system

5 4 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

6 5 Dr. Aumran Tahir Co-Director, Integrated Care Pilot

7 6SOURCE: NWL interviews Providing joined up care for patients is the central idea of the ICP Meanwhile, Joe, falls on the way to the toilet and breaks his hip. At the hospital, he has hip surgery and his memory deteriorates. By focusing on preventative care and the promotion of well-being, for example Joe may have been indentified as needing a falls assessment and fracture prevention. Annie contacts the Out of hours service whose GP prescribe antibiotics and ask the District nurses to visit. Had there been integration with health care providers Joe would have had a social worker assigned and contact details of all professionals would be available. The DN visits the next day and asks Annie to contact the council for additional help. At the council, Suzie tells them she needs some time to sort out the paperwork If Suzie had integrated IT systems and access to Joe’s care records; she would have known that Joe is an individual who required additional care quickly. She may have already put in place additional support. Annie is unable to look after him at home any more, so Joe is discharged to a nursing home after a lengthy stay in hospital. Even if Joe’s fall couldn't have been avoided and he was admitted to hospital; community care would have known about Joe’s condition and planned for a speedy discharge. Joe, 85 years old, mild dementia, lives at home with his wife Annie. He develops a low-grade urine infection and as a result is increasingly confused and has reduced mobility. Joe would be indentified as patient in need of an integrated care plan. His care plan would be available to all health care professionals involved in his care and in the ICP. Crucially he and his carer would have a copy of the care plan.

8 7 Over the course of the pilot we aspire to transform care for a population of 750,000 people across six boroughs Background for Integrated care in North West London – for people with diabetes and the elderly Practices serving up to 375,000 patients are already working with the pilot to start delivering integrated care for their patients with diabetes and the elderly Hounslow: ~40,000 patients Kensington and Chelsea: ~35,000 patients Westminster: ~63,000 patients Acton: ~54,000 patients Hammersmith and Fulham: ~185,000 patients

9 8 What’s the big idea? Local Multi-Disciplinary Groups……working in a Multi-Disciplinary System Patient registry Risk stratification Clinical protocols & care packages Case conference Performance review Care plans Care delivery Improve the quality of patient care for patients with diabetes and the elderly Group Mental Health Specialist Sub-Group Social care Specialist Acute Specialist Community matron Practice Social care worker District nurse Community Mental Health Practice nurse GP

10 9 What are the key enablers? Aligned Incentives through an innovative financial model Information sharing to access and analyse data in a timely fashion Joint Governance through IMB with a shared performance and evaluation framework Organisation and culture development Patient, user and carer engagement and involvement

11 10 What does the Multi-Disciplinary system consist of? 1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review Risk stratification 2 Shared clinical protocols 3 Community pharmacist Practice nurse Social care worker District nurse GP Community Mental Health Care delivery 1 5 Performance review 7 Case conference 6 Patient registry 1 Care planning 4

12 11 Providing integrated care can have a significant impact for the patients and for the health system as a whole GP ▪ Save 12 avoidable admissions per year per ~2,000 patients Practice ▪ Save 48 avoidable admissions per year per ~8,000 patients Pilot ▪ Save 2,215 avoidable admissions per year across the pilot population of 375,000 Catchment ▪ Save 4,430 avoidable admissions per year across the catchment population of 750,000 ▪ In the steady state the pilot aims to save 1 avoidable emergency admission per GP per month by providing more joined up planned care to patients in the pilot pathways

13 12 Evaluation Metrics for IC Pilot Reduction in Activity ▪ Emergency admissions ▪ A&E attendances ▪ Emergency inpatient days ▪ Prescriptions Impact on Operations ▪ Patients on care plan ▪ Adherence to care plan ▪ Average length of stay ▪ Quality of care planning ▪ Community nursing hours per patient ▪ Bed occupancy rate Quality of Care ▪ Acute re-admissions ▪ Control measures ▪ Reduction in long-term care needs ▪ Waiting lists for non-acute care ▪ Hard outcomes (incl. PROMs) ▪ Patient experience metrics (incl. PREMs) Staff engagement ▪ Attendance at MDGs ▪ Staff-satisfaction with IC pilot ▪ Quality of MDG interaction SOURCE: Evaluation Working Group The pilot will also be evaluated on four other key dimensions

14 13 The pilot will be governed via an Integrated Management Board (IMB) which is an association of all participating members Chair of Integrated Management Board General Practice Acute providers Community Health Local Authorities Mental Health Patient reps and third sector ▪The legal documents signed by all the parties also facilitate –Creation of IMB and its processes and procedures –Assure process around funding flows –Setting of the information governance framework allowing access to the IT tool –Arrangements for data sharing among the ICP Partners –Ensure mutual accountability and collective decision making

15 14 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

16 15 Dr. David Gable Consultant, Imperial College Healthcare NHS Trust Lead Clinician, Westminster Diabetes Partnership

17 16 The pilot is supported by a custom IT portal which enables four key elements of integrated care Risk stratificationCare Planning EvaluationInformation Sharing  Plan care for patients, share these plans across settings, and monitor progress  This helps better coordinate care  Track and evaluate the performance of GP’s surgeries and Multi-Disciplinary Groups  This helps spread best practice in patient care  Identify high risk patients using population segmentation and risk stratification  This enables proactive care to be planned  View patient medical information from multiple settings  This enable integrated care to be provided Care plan Action 2 Action 3 Action 1 Action: Review by falls service Action status: Completed Patient records: GP Hospital Community

18 17 The ICP Web Portal can be used to identify high risk patients The risk stratification screen allows health care professionals to identify high risk patients They can then click on any of the bars in the graph to see which patients fall into that risk category A number of different metrics can be used to help in this task

19 18 Integrated Care Plans help coordinate the care for patients within the Pilot Text The Portal can be used to create and manage Integrated Care Plans for patients Standard care packages can be selected by clicking on any of the template buttons, the actions in this care plan will then be selected Individual actions can then be added or removed from the care plan

20 19 The portal can also be used to share patient information across settings This screen shows some basic information about the patient It also shows the patients prescription history The prescription history can be filtered and sorted to better be able to find information

21 20 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

22 21 Dr. Jennifer Durandt GP Mill Hill surgery Acton

23 22 What’s happening in Acton? …supported by monthly Multi-Disciplinary Case Conferences for discussing complex patient cases Twelve practices… …serving 54,000 patients… …with a new full time elderly care specialist nurse and additional diabetes specialist sessions… …and a new service connecting GPs and acute consultants… What's new?

24 23 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

25 24 Chris Ham Chief Executive, King's Fund

26 25 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

27 26 What does the ICP pilot mean for you, your organisation and your patients? ▪ Dr. Mark SpencerMedical Director NHS North West London GP, Hillcrest surgery Acton ▪ Dr. Jonathan ValabhjiConsultant Physician Imperial College Healthcare ▪ Dr. Iňaki BovillConsultant Physician Chelsea and Westminster Hospital ▪ James ReillyChief Executive Central London Community Healthcare ▪ Roz RosenblattLondon Region Manager Diabetes UK ▪ Benn KeaveneyAge UK ▪ Cath AttleeAssistant Director Joint Commissioning Westminster City Council

28 27 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

29 28 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

30 29 Anne Rainsberry Chief Executive, NHS North West London

31 30 What’s different about the integrated care pilot? ▪ Model based on aligned financial incentives ▪ Use of guidelines and international best practice ▪ Shared accountability for performance ▪ IT supports delivery ▪ Multidisciplinary groups where generalists work alongside specialists to deliver integrated care ▪ Patient and clinician driven ▪ Collaborative culture New way of working Factors for success

32 31 What’s next for integrated care in North West London? ▪ Roll out across more practices in North west London ▪ Enhance integration with local authorities and other providers ▪ Continue to develop and enhance the IT tool ▪ Conduct robust evaluation at the end of the pilot year to track impact

33 32 Working together we can make the Integrated care pilot a real success

34 33 Agenda ▪ Welcome and Introduction 11:30-11:35 ▪ What is the integrated care pilot? 11:35-11:50 ▪ Panel discussion 12:10-12:35 ▪ Summary and wrap up 12:45-12:50 ▪ Refreshments and networking 12:50-13:30 ▪ What’s happening on the ground - Acton11:55-12:00 ▪ Importance of integrated care in NHS12:00-12:10 ▪ A brief overview of the IT support tool11:50-11:55 ▪ Questions and Answers12:35-12:45

35 34 Appendix A0 Posters

36 35 What are we trying to achieve in NWL? 1)Become a ‘beacon’ for delivering integrated care to the local population involving primary, secondary, community, social and mental health sectors 2)Significantly improve patient experience 3)Decrease emergency admissions by 30% and nursing home admissions by 10% for diabetics and frail elderly through better more proactive care 4)Reduce the cost of care for these groups by 24% over 5 years Practices serving up to 375,000 patients are already working with the pilot to start delivering integrated care for their patients with diabetes and for the elderly Over the course of the pilot we aspire to transform care for a population of 750,000 people across five boroughs Background for Integrated care in North West London – for people with diabetes and the elderly Hounslow: ~40,000 patients Kensington and Chelsea: ~35,000 patients Westminster: ~63,000 patients Acton: ~54,000 patients Hammersmith and Fulham: ~185,000 patients

37 36 Local Multi-Disciplinary Groups……working in a Multi-Disciplinary System Patient registry Risk stratification Clinical protocols & care packages Case conference Performance review Care plans Care delivery Improve the quality of patient care for patients with diabetes and the elderly Group Mental Health Specialist Sub-Group Social care Specialist Acute Specialist Aligned Incentives through an innovative financial model Information sharing to access and analyse data in a timely fashion Joint Governance through IMB with a shared performance and evaluation framework Organisation and culture development Patient, user and carer engagement and involvement What’s the big idea? Community matron Practice Social care worker District nurse Community Mental Health Practice nurse GP

38 37 What does a Multi-Disciplinary Group do? 1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review Risk stratification 2 2 Shared clinical protocols 3 All providers in the MDG agree to provide high quality care as laid out in the Pilot’s recommended pathways and protocols 3 Community pharmacist Practice nurse Social care worker District nurse GP Community Mental Health Care delivery 1 5 Patients receive care from a range of providers across settings, with primary care playing the crucial co-ordinating role and every body using the ICP IT tool to coordinate delivery of care 5 Performance review 7 The MDG meets regularly to review its performance and decide how it can improve its ways of working to meet the Pilot goals 7 Case conference 6 A small number of the most complex patients will be discussed at a multi-disciplinary case conference, which will help plan and coordinate care 6 Patient registry 1 Each MDG holds a register of all patients who are over the age of 75 and/or who have diabetes – these patients are part of the Pilot 1 Each patient is then given an individual integrated care plan that varies according to risk and need 4 Care planning 4 The MDG uses the ICP information tool to stratify these patients by risk of emergency admission

39 38 The pilot is supported by a custom IT portal which enables four key elements of integrated care Risk stratificationCare Planning EvaluationInformation Sharing  Plan care for patients, share these plans across settings, and monitor progress  This helps better coordinate care  Track and evaluate the performance of GP’s surgeries and Multi-Disciplinary Groups  This helps spread best practice in patient care  Identify high risk patients using population segmentation and risk stratification  This enables proactive care to be planned  View patient medical information from multiple settings  This enable integrated care to be provided Care plan Action 2 Action 3 Action 1 Action: Review by falls service Action status: Completed Patient records: GP Hospital Community

40 39 The ICP Web Portal can be used to identify high risk patients The risk stratification screen allows health care professionals to identify high risk patients They can then click on any of the bars in the graph to see which patients fall into that risk category A number of different metrics can be used to help in this task

41 40 Integrated Care Plans help coordinate the care for patients within the Pilot Text The Portal can be used to create and manage Integrated Care Plans for patients Standard care packages can be selected by clicking on any of the template buttons, the actions in this care plan will then be selected Individual actions can then be added or removed from the care plan

42 41 The portal can also be used to share patient information across settings This screen shows some basic information about the patient It also shows the patients prescription history The prescription history, can be filtered and sorted to better be able to find information


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