Integrated Care NIS 2015-16

Tower Hamlets vision: Working together for better quality, person-centred care

The population Nelie risk: to identify those at high risk of admission Clinical judgement important 3 emerging groups: Complex needs: (LYOL, care homes, dementia etc.) Transition: acute community Long term conditions

Context of revised NIS AUA DES-overlap of populations and requirements  Feedback from front-line clinicians (number of changes, need for stability)  Maintain the same level of investment 

Changes Adding a new population: 4.1-6% for entry level care: consent Patient activation measure (PAM) –measures skills, knowledge, confidence for self-management. Qnnaires for Level 2 patients, 13 questions, x2 qnnaires, both scores to be coded

PAM http://www.insigniahealth.com/solutions/patient-activation-measure/what-a- pam-score-reveals

In summary  Population Entry level-consent (£10) Level 1: crisis plan (£90) and named clinician (£5) Level 2: personalised planning process including LYOL care (£110) and PAM (£5 x2) 4.1-6%  Top 4% 4 mandatory categories and old discretionary