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‘Integrated Care Teams’ QIPP Long Term Conditions Dr J John National Clinical Associate in LTC/QIPP Department of Health 19 th July 2012 Kent and Medway.

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Presentation on theme: "‘Integrated Care Teams’ QIPP Long Term Conditions Dr J John National Clinical Associate in LTC/QIPP Department of Health 19 th July 2012 Kent and Medway."— Presentation transcript:

1 ‘Integrated Care Teams’ QIPP Long Term Conditions Dr J John National Clinical Associate in LTC/QIPP Department of Health 19 th July 2012 Kent and Medway LTC Programme

2 Statistics 70% of health and care spend No LTC = Around £1,000 50% of GP appointments 70% of inpatient bed days 68% of outpatient & A&E appointments 3 or more LTC = Circa £8,000 1 LTC = Circa £3,000 Long term conditions represent… The average annual health cost… 170,000 people die prematurely of long-term conditions each year Significant variation across PCTs exists in emergency hospital use

3 60% The Case for Change 252% rise just in Diabetes by 2050 188% increase in the number of patients with multiple LTCs by 2013 rise in over 65 year olds by 2050

4 Current Spend 2011 Projected Spend 2016 Pay: 3+ Long Term Conditions Date: 2011 Amount in Words: Nineteen Billion Pounds Signed: __________ £19,000,000,000 Pay: 3+ Long Term Conditions Date: 2016 Amount in Words: Twenty Six Billion Pounds Signed: ___________ £26,000,000,000 The Case for Change No health care system is sustainable in the face of this tsunami of need

5 The systems perspective The patient perspective Too many admissions & readmissions Too much activity in secondary care Too much reactivity/not enough proactivity Need more integration between services High Anxiety Low levels of confidence in managing own health Low levels of health literacy Confusing system to navigate Reliance on system in times of real or perceived need

6 QIPP LTC Workstream Primary drivers: Risk Profiling Integrated care teams at locality level Systematic empowerment of patients to self manage

7 Integrated teams Improved health status, reduced weight and improved diet 1,4 People were most likely to be alive, living independently at home 6 Improved symptoms and behaviours 5 Improved health status & mental well-being. Outcomes for lower cost 3,7 Source: (1) Kasper “A Randomized Trial of the Efficacy of Multidisciplinary Care in Heart Failure Outpatients at High Risk of Hospital Readmission”. Journal of the American College of Cardiology Vol. 39, No. 3, 2002 Source: (2) Griffiths. “Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme”. Thorax 2001;56:779–784 Source: (3) van den Hout “Patient team care nurse specialist care, inpatient team care, and day arthritis: a randomised comparison of clinical multidisciplinary care in patients with rheumatoid”. Ann Rheum Dis 2003 62: 308-315 Source: (4) Capomolla et al. “Cost/utility ratio in chronic heart failure: comparison between heart failure management programme delivered by day-hospital and usual care” J Am Coll Cardiol 2002; 40: 1259-66 Source: (5) Opie, Doyle & O’Connor “Challenging behaviours in nursing home residents with dementia: a RCT of multidisciplinary interventions” Int J Geriatr Psychiatry 2002; 17(1):6- 13 Source: (6) Stroke Unit Trialists’ collaboration “Organised inpatient care for stroke” Cochrane Library, issue 2, 2004 Source: (7) Ahlmen et al “Team vrs non-team outpatient care in rheumatoid arthritis” Arthritis Rheum 1988; 31(4): 471-9

8 The Vision in ONEL Population Size: 236,000 Population Size: 180,000 Population Size: 270,000 Population Size: 227,000 41 GP Practices 54 GP Practices 45 GP Practices 47 GP Practices  Coordinated care for patients and carers in the community  Optimal patient experience and clinical outcomes  Lower cost, better productivity  Whole system change (1,000,000 patients)

9 Outline / Aims of the Project Providing Integrated Care services where “the patient receives the care that they want and nothing more; the care that they need and nothing less”. Partnership working between the GP practice, Social services and provider services. Avoids duplication of services. Aims:Integrated Teams

10 Provides proactive management of long term conditions and social needs. Prevents avoidable hospital admissions because of robust planned care and patient education Reduction in permanent admissions to residential and nursing homes

11 Component Parts of ICM Risk Stratification Co-ordinated care plans Collaborative team working Patient Feedback Measurement and monitoring Provision of care to patients Networking with associated services

12 ONEL :Integrated Care Team Patient /Carer GP Community Matron Social WorkerDistrict Nurse Practice Nurse (Optional) Care liaison officer OT Therapies Acute care specialist s End of Life Mental health Voluntary Sector Drug & Alcohol services

13 *Named District Nursing Sister and allocated Band 5 Community Nurse GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtua l) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual ) GP PRACTICE x5 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) CLUSTER 1 CLUSTER 2 CLUSTER 3 CLUSTER 4 CLUSTER 5 CLUSTER 6 The Model:Co located

14 Community Planned Care (health & social care) Community Planned Care (health & social care) Access Integrated Case Management Overview Identify Service User High Risk patients identified via Health Analytics and Clinical Expertise The Integrated Care Team - GP - Community Matron - Social Worker - District Nurse - Integrated Case Coordinator - Additional Specialist / Voluntary Sector as needed. Case Conference & Care Plan Fortnightly meetings at practice level High risk patients discussed and care plan Implemented Care Delivery Care delivery by Integrated Team as coordinated by Integrated Care Coordinator with the patient Ongoing Care Onward Referral Self Management Care Plan Review Single point of access Provides 24/7 Nursing / Reablement to prevent hospital admissions and support early discharge Works in partnership with Out of Hours GP services to prevent hospital admission Works in partnership with the London Ambulance Services in full to prevent hospital admission Admits Patients to step up community beds to provide short term interventional care Rapid response underpins the integrated care model and provides nursing /reablement unplanned care 24/7 up to 14 days to prevent hospital admissions and promote early supported discharge Community unplanned care (health & social care) Rapid Response

15 Experience based design videos to co-own/produce new ways working Workstreams- coproduction Visits undertaken to more than 140 GP practices in ONEL Stakeholder engagement events organised for each borough Meetings with each stakeholder – social services, community provider, acute trust, Public health, Voluntary ONEL strategy sessions Feedback from patients / pilot sites at B&D Outline case presented to each stakeholder Research activity to identify best practice Significant time spent by the QIPP team in shaping the model of care. DH support/Visits to other sites for learning Business cases, Practice support,Estates Governance agreements/documents Modelling activity to determine savings Stakeholder engagement Planning/ Implementation Planning and Implementation Integrated Care programme

16 Case Study 1 Patient BM 80 year old F in top 1% who needed more intervention as time progressed MHX: AF, CCF, Hypertension, PVD, COPD under 4 specialist teams (London and local) Social: Lives alone, help from niece, carers going in twice a day Pre IC:  No feed back from disciplines frequent hospital admissions  no team approach to patient  poor outcomes  depression Pre IC:  No feed back from disciplines frequent hospital admissions  no team approach to patient  poor outcomes  depression Post IC: More joined up working More effective use of services in the community Patient feels more supported Trying to address key issues (pain) and more accountable ownership of particular patient problems via specialist teams in the community Post IC: More joined up working More effective use of services in the community Patient feels more supported Trying to address key issues (pain) and more accountable ownership of particular patient problems via specialist teams in the community

17 Overall Outcomes Quality Outcomes  Over 1300 patients with MDT care plans in place  132 GP practices, 3 local authorities, 2 acute trusts and 1 community provider delivering the model of care ( Integrated Care Coalition)  Improved co-ordinated care by multi-disciplinary teams and reduced duplication  Every patient has a nominated and dedicated coordinator to coordinate personalised care  Rapid access to social care as needed through direct referral to social care

18 Social Care Improvements Reclaiming social work Shared risk taking Improved referral pathway Locality working – personalisation spin offs Hospital in-reach Reduction in admissions to residential care Significant increase in SDS performance

19 Overall Outcomes Financial Outcomes  Reduction in length of stay for patients with LTC in comparison to 10/11. 12% reduction in Waltham Forest and a 9% reduction in Redbridge, 10% in B and D  Reduction in the number of referrals to nursing / residential homes  Increased timeliness of care packages  Reduction in the number of safeguarding referrals

20 Overall Outcomes Operational Outcomes  Transformational community nursing workforce development  Co-location of health and social care teams in B&D and Redbridge building “high trust” partnership teams  Establishment of strong collaborative working with primary/ community teams and secondary care to support patients across the pathway  Full roll out of integrated data platform to integrated health intelligence from acute, GP, social care and community data sources across all boroughs to target appropriate patients for model of care  Improvement in staff retention in services  Now a site for – ‘Year of Care Pilot’ for the DH

21 Support Website, Update, Resources, Virtual programme, LTC Commissioning Pathway Local Support- National Coach (DH) and Queens Nurse- Sharon Lee

22 Future The best way to predict the future is to create it Peter Drucker


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