Integrated Care Management

Population Management Model Supported Self Care Care Management Health Promotion Population wide prevention Care coordination Most Complex Range of risk Education Lifestyle

What is Integrated Care Management ? Proactive approach High risk patients Medical/nursing/pharmaceutical/social needs Undertaken by Qualified Professional Suitable trained and competent

What does it involve? Full assessment medical, nursing, pharmaceutical and social care needs Develop personalised holistic care plans Involve patients and carers as partners Highly visible Lead role Secure services/ treatments modalities Teach pt/ carers monitor condition Maintain contact through hospital admissions Cross boundary working

Potential Benefits Better outcomes for individuals, their families, carers and communities Improved access to services Reduction in the use of unplanned care Improved concordance with medication Improved partnership working Reduction in the number of professionals involved in the individuals care Improved choice Greater continuity of support / care / involvement More control in the package of care / support provided Improved and speedier decision making Empowerment of individual through active participation in the process

Care Managers Training(Health Staff) Advanced clinical assessment skills Physical examination skills Minor Major Illness Injury Nurse Treatment Service (MINTS) Independent and Supplementary prescribing Care Management Training

Lanarkshire Pilots 12 month pilots Outcome Measures Admission rates, LOS, pharmaceutical care, GP attendances, clinical consultations, equipment, social care service utilisation, patient, carer, staff satisfaction Most effective approaches rolled out across Lanarkshire

Lanarkshire Locality pilots

High Risk by Gender

High Risk : Total Bed Days used

High Risk group and number of Emergency Admissions

Emergency Admissions Vs Total Bed Days

Principal Diagnosis of High Risk

High Risk cohort by Probability

Probability Vs Diagnosis

SPARRA Outcomes in Lanarkshire

38%

Shared Learning