1 North East Leicester PbC Cluster Extended Integrated Care Team Dr Nitin Joshi – GP & Project Lead Clinician Tracey Shepherd – Locality General Manager Michelle Beasley – Project Manager, Personalised Care Plans

2 Hypothesis Does a whole systems approach to integrated care lead to better quantative and qualitative outcomes?

3 NEL Commissioning Group The wider context 7 Practices Population 44, % Patients Over 65 vs. PCT 11.6% Disease Prevalence rates higher than PCT average CHD Heart Failure Stroke Hypertension COPD Asthma CKD

4 Timeline November 2007 – Unique Care Pilot March 2010 – Presented Business case to expand project July 2010 – funding received and EICT Project commenced August 2010 – Link with QIPP LTC workstream

SIMPLE SYSTEMS ‘one size fits all’ ‘mono’-morbidity Good mental health Well defined groups Defined interaction with secondary care COMPLEX SYSTEMS Need individual care plans Multi-morbidity Mental health complications Poorly defined groups Poorly defined interaction with secondary care

SIMPLE SYSTEMS ‘one size fits all’ COMPLEX SYSTEMS Need individual care plans Integrated team Mental health worker Risk stratification Acute care group primary care physician Personalised care plans ‘mono’-morbidity Good mental health Well defined groups Defined interaction with secondary care Multi-morbidity Mental health complications Poorly defined groups Poorly defined interaction with secondary care

7 All patients of NEL cluster Best practice, Map of Medicine and Medicine Management Risk Stratification Tool Pilot and other intelligence to identify patients at risk patients Practice Nurse Social Workers District Nursing UHL (Acute Sector) Proactive Admission Management & Discharge Planning Early Discharge Pathways Community Matrons Mental Health Worker Appropriate Treatment In reach nurse Patient Pathway GPs Extended Integrated Care Team

8 The Business Case Focus 2008/09 NEL Cluster Higher than PCT average spend for: Total Non Elective Admissions Excess Bed Days Prescribing The KPMG 6 identified conditions Cellulitis Lower Respiratory Tract (without COPD) Lower Respiratory Tract (with COPD) Congestive Heart Failure UTI Dehydration

9 Handbook example

10 Handbook example

11 Handbook example

12 Case and Load Management Meetings

13 Activity Targets Forecast Activity Targets Forecast Activity 2009/101st Year2nd Year 10%20% ££ Cellutitus53511 Lower Respiratory tract infections without COPD Lower Respiratory tract infections with COPD Congestive Heart Failure3337 UTI Dehydration301 6 conditions identified by KPMG as a potential PCT saving of 35% of Acute cost PrescribingNA Excess Bed days (5% year one and 10% year 2) Activity

14 Summary 6 Months (April 10- Sep 10) ConditionActualTarget Diff from Target Respiratory Conditions without COPD Respiratory Conditions with COPD Congestive Heart Failure Dehydration 422 UTI Total ALL Summary - Non-Elective admissions against Target for 6 Priority Conditions for First 6 Months ( April 10 - September 10) All Providers. Evidence so far

15 Evidence so far Emergency non-elective admissions

Evidence so far

17 Personalised Care Plans Patient held & led record Communication Tool Holistic approach Support for self management Developed by a stakeholder group Excellent ‘fit’ with the pilot QIPP programme helped gel together

18 What they say Zoe Harris - Community Health Nursing Lead Anne Forde – Adult Social Care “Personalised care planning is the only way to work as it puts the individual at the heart of their support. It focuses the workers on the individuals, goals, wishes feelings, needs and what's important to that person to support them and enable well being”. Mark Pierce – Commissioner NHS Leicester City “Personalised care plans have great potential to contribute to improvements in patient outcomes. They can offer commissioners a window on the workings of the services they commission. They also offer an insight into how patients experience their illnesses and as such can be of interest to any commissioner.” “My experience of PCP’s for level three patients is that they can be an effective way to ensure quality care for individuals with LTC’s particularly when they include the patients own self management plan when they experience an exacerbation of their condition and also to record their wishes for end of life care”.

19 What they say Diana Osbourn – patient “It is fantastic that my wish to have more control and responsibility over management of my Long term Condition has at last been acknowledged and that I will be able to really work in partnership with my GP & Health Specialists to prioritise what is important to me” Patient “ Less time wasted on duplication and reducing my visits to the GP/Doctor, saves time & money for me & the NHS - it’s a winner all round! “ John Cook – patient "I am sure that the joined up thinking, at the heart of this project will help NHS become more effective and efficient benefiting practitioner and patient” Dr Maini, EICT Project GP “A cohesive way of working that benefits patients and health professionals alike”

20 What they say Project Lead – Personalised Care Plans The reaction from patients and voluntary groups especially has been one that “We are really ready for this, and are looking forward to help manage our conditions the way that works best for us, working in partnership with our key workers “ Social Worker Bhavna Maher EICT Project “Services will benefit greatly if health and social care professionals work in partnership” ’’’’ Integrated Care Project “Excellent to see how joined up thinking and working can save £’s as well as lives – and that it is actually working!”

21 Where Next Handbook Web pages/ YouTube Risk Stratification Recruitment of MHNS Recruitment of 2 In Reach Nurses Project survival in the current changing climate

2 Hypothesis Does a whole systems approach to integrated care lead to better quantative and qualitative outcomes?