1. ProMISE Proactive Management and Integrated Services for the Elderly ProMISE The Bromley Programme Sam Merridale, Programme Lead June 2012

2. ProMISE Proactive Management and Integrated Services for the Elderly The Local Context Large ageing population >16% in 2011 Diabetes, cardiac and respiratory commonest cause of ill health Carers and dementia probably under recognised Current service delivery often fragmented & reactive

3. ProMISE Proactive Management and Integrated Services for the Elderly The Vision Improve the health of our older population with complicated health & social needs in Bromley

4. ProMISE Proactive Management and Integrated Services for the Elderly The Goals Inform patients and promote independence Identify most vulnerable & over 65 Design care plan around the patient’s needs Manage their care through coordinating services effectively

5. ProMISE Proactive Management and Integrated Services for the Elderly The Objectives Develop a tool to identify most vulnerable Create a cohort of people “virtual ward” Design patient-centred care-plan Deliver quality service-coordinated, targeted and appropriate Promote self-care and education for patient & carers Improve communication between care-givers

6. ProMISE Proactive Management and Integrated Services for the Elderly

7. ProMISE Proactive Management and Integrated Services for the Elderly Outcomes Improve clinical outcomes, reducing unplanned admissions and length of stay in hospital Improve patient’s experience, broadening their understanding of their health needs and self-care measures

8. ProMISE Proactive Management and Integrated Services for the Elderly Developing a Culture Shift Key driver is to improve care for our older population Need for better respect, improved understanding, shared commitment, opportunities for learning & support-> effective collaborative working

9. ProMISE Proactive Management and Integrated Services for the Elderly The next step-Phase One 2 community matrons & 2-3 GP Practices Testing out the pathway with existing services Results & progress will inform and enable us to improve and refine services based on active cases Start education programme in primary care

10. ProMISE Proactive Management and Integrated Services for the Elderly Programme Implementation Managed process Programme management team – meet weekly Agree programme structure, priorities and case for change Engagement – critical to success

11. ProMISE Proactive Management and Integrated Services for the Elderly Programme Governance Programme Board – responsible for all decisions and moving the programme forward Clinical Advisory Group Stakeholder Reference Group Programme Implementation Group

12. ProMISE Proactive Management and Integrated Services for the Elderly Accountability Health and Wellbeing Board – Financial oversight of shared budget Bromley Clinical Commissioning Executive Bromley, Bexley, Greenwich Programme – Clinical Strategy Group

13. ProMISE Proactive Management and Integrated Services for the Elderly Stakeholder Engagement Primary care clinicians London Borough of Bromley Bromley Healthcare South London Hospitals NHS Trust Oxleas Trust London Ambulance Service Bromley Links Bexley CCG Greenwich CCG NHS SL Cluster St Christopher’s Voluntary Sector EMDOC … etc

14. ProMISE Proactive Management and Integrated Services for the Elderly Interesting issues!! Case finding – using risk stratification, but also clinical knowledge Data sharing – across organisational boundaries, and critical to success Metrics for evaluation – must be consistent with others Telehealth – explore the principles of how this will support true integrated care – it’s not just about expensive gadgets