1. Multimorbidity Action Plan Dr Anne Hendry Dr Frances Elliot

2. Enabling People to Live Well “Making care truly person-centred requires radically different ways of thinking….. If we are to see truly collaborative approaches to healthcare, we will need not only those change mechanisms with which we are familiar.. But also conversation and space that enables people to understand, reflect upon and reconsider their purpose, attitudes, roles and relationships“

3. Top Ten Improvement Actions LTC Collaborative Risk prediction in primary care Case Management Anticipatory Care Plans Support for Self Management Intermediate care Telehealth and Telecare Reablement and Rehabilitation Medicine reconciliation & pharmaceutical care Reduction in delayed discharge Hospital pathways for frailty and delirium LTC Collaborative 2008 – 2011 Boards delivered 14% reduction in bed day rate for COPD, Asthma, CHD and Diabetes between 2006/07 – 2010/11

4. Multimorbidity – 3 Workstreams 1. Micro system - Care planning and consultations that help people to have control over their conditions, care and support and achieve their personal outcomes Build on the PPHWB and ACP/ polypharmacy work; Adopt House of Care in General practice 2. Meso system - Technology enabled care and support that builds on community assets to promote independence, wellbeing and resilience Spread Improving LINKS, ALISS and community facing primary care; Scale up 3 THC priorities - Lite touch remote monitoring ; Apps for self management; virtual consultations 3. Whole system pathways that are designed around Multimorbidity and to reduce health inequalities Develop integrated locality arrangements that engage MCNs and deliver care coordinated across the whole pathway by a lead professional / named person Visible adaptive leadership and a coherent research, innovation and improvement infrastructure that drives excellence in Integrated Care for Multimorbidity

5. New Paradigm for Measurement Primary Care: Long term conditions care planning Integrated care Intermediate care: NHS rehab / enablement at home/day hospital Care management/ anticipatory care: Community nursing Mental Health: Recovery support NHS Self-Management Support: Self-management programmes/ psychological interventions

6. Data about individuals Locality data Partnership / LA / Board data (local measurement) Partnership / LA / Board outcomes & indicators (national focus) National Performance Framework & other key national indicators Catriona Hayes

7. Draft measurement framework: Multiple morbidity LevelExamples of measurement IndividualsImprovement in Personal outcomes; uptake of Self Directed Support; Anticipatory Care Plans; KIS accessed LocalitiesAggregated personal outcomes data for commissioning; Locality information to understand need and target support; General Practice data ; user feedback; improvement of process; Demand and capacity data for planning to support client needs; Workforce and financial resources Partnership / LA / Board (local report) Aggregated and comparative locality data to understand overall performance, variation and inequalities within the partnership Partnership / LA / Board (nationally available) National patient experience surveys (including integration indicators); hospital activity and delays; QOF data NationalSelf-assessed General Health; Mental wellbeing; Support for people with care needs; Hospital activity and delays; Healthcare experience; Physical activity

8. Lessons from RCOP Takes time to reach consensus and build will across multiple partner organisations Significant lead time for partnerships to test innovations, particularly statutory organisations Pressured to get maximum gain from a one year £100M Integrated Care Fund Urgent need to accelerate organisational readiness in the next 6 months and increase capability to drive the MM actions and deliver outcomes ‘Resource light collaborative’ - eg Dementia Improvement Programme Programme management support required to engage partnerships, secure traction and ensure coherence with other improvement work Information resource required to develop and support use of a meaningful measurement framework