Transforming Care for People with Long Term Conditions and the Frail Elderly. Across Mid Nottinghamshire. The total cost of the physical health and social care economy is . £398m. .. The . 19m funding gap . ID: 339466
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Integrating Care across Mid Nottinghamshire
Transforming Care for People with Long Term Conditions and the Frail Elderly
Slide2Across Mid NottinghamshireThe total cost of the physical health and social care economy is £398m.The 19m funding gap from 2012-13 could increase to at least £70m, and possibly be more than £100m by 2018.
2
5 Year Financial gap = £70m
10 year Financial gap = £140m
Our financial challenge
Slide3Quality of life
We have a vision for the next five years
£1
£10
£100
£1,000
ICU
ACUTE CARE
0%
COMMUNITY
CARE
Self-management
Long Term Condition Management incl Cancer
Third sector provision
Primary Care
100%
Consultant-led services
Specialist teams
Specialty
Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT
LEFT
£5,000
Cost of Care per Day
Risk profiling
Slide4Patients and healthcare professionals told us that services were….
Disease
specific – patients often under the care of 3 or more different teams / individuals
Fragmented, with poor communication between teams
Isolated – Silo services with health and social care working in isolation
Confusing – HCPs and patients don’t always know what services are available and how to refer to them
Frustrating, with lengthy referral times / waits
Inconsistent, with patients falling through the gaps
Limited, particularly in relation to a lack of out of hours cover – only option for some is 999
Overloaded, especially primary care and community services
Reactive – care is based around crisis management
Slide5Our Vision
To work collaboratively with our partners across the health economy to:
Transform the way we deliver care by creating a whole system, fully
integrated hospital, community, primary and social
care model.
I
mprove
outcomes for patients with Long Term
Conditions
and the frail elderly.
Create
access to better, more integrated care outside of
hospital
Reduce
unnecessary hospital
admissions
Enable more
effective working of healthcare professionals across provider boundaries
.
Address the significant economic challenges ahead
Slide6Our Partners
Sherwood Forest Hospitals Foundation Trust
Health Partnerships ( Community and Mental Health Services Provider)
Nottinghamshire County Council
Newark and Sherwood District Council
Newark and Sherwood CVS
Self Help Nottingham
Patients
Carers
Slide7Integrating the management of cancer as a long term condition
Slide8This is Albert
76 years oldEx MinerHeart FailureDiabetesHypertensionHistory of alcohol abuseHe is married to Mary who is 74. She has osteoporosis, diabetes and arthritis. They live in a 3 bed ex council house in a rural area with a dog called Fred and have lost touch with most of their friends. They have 3 children who all live away.
Slide9Slide10Principles of the New Approach
Radical
– Completely redesign the system across the entire health economy.
Work in partnership with all partners organisations
A focus on proactive care to anticipate and prevent crisis
Primary Care at the heart of the system – A community based model
Systematic profiling and risk stratification
of the whole population and systematic streaming into dedicated services.
Integration of care
across the health and social care economy
Personalised care designed around the patients’ needs
Care planning and shared decision
making to become systematically embedded into every day practice
Increased access to services around the clock and out of hours
Recognition of the need to
invest and commitment to do so
Slide11Risk Stratification
Slide12Risk Stratification
Using risk profiling software –
The Devon Tool
available to all GPs in all practices.
Combined Predictive Model developed and utilised in Torbay ICP.
Demonstrated 86% accuracy in predicting future admission
Utilised in 2 ways
Service Planning and commissioning
Practice Level Patient Identification
Slide13Devon Tool for Systematic Risk Profiling to identify risk
Top 0.5%
Community Matron / Virtual Ward as part of
Multidisciplinary Team
(Community Geriatrician, GP, Social Care, Therapists, Rehab, Domiciliary )
Care Planning and individual personalised care plan
Disease Specialist Input where required from specialist community teams ( COPD, Diabetes)
Telehealth
and Tele CarePsychological SupportPlanned hospital admission , proactive in reach and facilitated discharge where needed
0.6-5%Intensive disease / case management by specialist teams as part of the MDTTelehealth / TelecareCommunity Specialist Services and clinics with MDT supportCare Planning and individual personalised care planPlanned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS
6-20%Proactive Disease Management by General Practice supported by specialist community services and teamsCare Planning and individualised Care planSupport to Self ManageEducation Programmes Annual ReviewSpecialist Medication reviews Anticipatory CareRemote monitoring via tele health where appropriate
Patients step up and down as risk profile changes
21% - 100%
Proactive Self Care Support and Management in Primary Care
Risk score recorded and reviewed annuallyActive Case FindingDisease Register Accurate diagnosisInformation PrescriptionsCare PlanningEducation relevant to patients needsDisease prevention andHealth promotion
HIGH RISK / Complexity
Low RISK / Complexity
Smoking Cessation, Health Promotion and Self Care
Admissions Avoidance
Public Health
Population wide Prevention
Disease awareness campaigns
Social marketing
Education
Health promotion
Schools
Workforce Development, Training and Education
Co-ordinated Social Care
Mid Nottinghamshire Integrated Model of Care for Long Term Conditions
Special Patient Notes / 24/7 Access to specialist support
Care Coordinator / Named Lead
1
2
3
4
Level
Slide14Slide15Integrated Care
Slide16Locality Based Integrated Care Teams
3 x locality based Multi-disciplinary teams / Virtual Wards
North ward launched Dec12, West Ward March 13, Newark Ward April 13
Each team comprising: ( all WTE posts)
Community Matrons
District Nurses
Occupational Therapist
Physiotherapist
Mental Health Worker
Social Worker ( directly commissioned from LA by the CCG)
Healthcare Assistants
Voluntary / Third Sector Workers – Part of the MDT
Ward Coordinator/ Manager
Slide17Underpinned by ………..
Specialist
case management teams ( Level 3) for COPD, Heart Failure and Diabetes
.
Community based
clinics ( CVD, COPD, Diabetes)
with commissioned consultant specialist
support
Community nursing teams and GP practice teams integrated
and aligned with each of the 3 ward teams throughout
Care
Homes integrated into the Virtual wards – people treated as if they were in their own home.
In the process of commissioning Community Geriatrician support
Increased provision of Intermediate care beds ( Step up and Step down)
Procurement of new Crisis Response Service ( June)
Slide18GP
GP
GP
2
Community Matrons
Community
Nurses
Occupational Therapist
Community Support Workers
Ward Co-Ordinator
Physiotherapist
Social Worker
Monthly Risk
Stratification
Named
Community Geriatrician
Named Specialist Nurse COPDHF DiabetesCancer
Dietetics
Tissue Viability
Continence
Crisis Response / Rapid Intervention Service
Voluntary Services
Community Specialist Teams
Diabetes/ COPD/ Heart Failure/ CancerLevel 3 Case ManagementStep Up Step Down between level 3 and level 4 ( Virtual ward)
Linked to
Extended Team
Support across all localities
Virtual WardCore Team
Podiatry
EMAS/ CNCS/ OOHs
Intermediate Care
Access to & Support from
Key
GP Practices/ Primary Care
Locality specific Virtual Ward / MDTs x 3
Cross locality support teams working across all localities and specialist disease management teams
CCG wide services
Specialist Community Teams – disease specific. Level 3 case management
Newark and Sherwood Integrated Team Model- LOCALITY VIEW
Mental Health Professional
Healthcare Assistants
Named
Community
Oncologist
Voluntary Services
There will be three localities , North, South and Newark.
The number of Virtual wards per locality will be dictated by the population and size. In areas where there is more than 1 virtual ward some roles will be shared between wards.
Comm munity Pharmacy
Medicines Management
Falls Team
Slide19Devon Tool for Systematic Risk Profiling to identify risk
Top 0.5%
Community Matron / Virtual Ward as part of
Multidisciplinary Team
(Community Geriatrician, GP, Social Care, Therapists, Rehab, Domiciliary )
Care Planning and individual personalised care plan
Disease Specialist Input where required from specialist community teams ( COPD, Diabetes)
Telehealth
and Tele CarePsychological SupportPlanned hospital admission , proactive in reach and facilitated discharge where needed
0.6-5%Intensive disease / case management by specialist teams as part of the MDTTelehealth / TelecareCommunity Specialist Services and clinics with MDT supportCare Planning and individual personalised care planPlanned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS
6-20%Proactive Disease Management by General Practice supported by specialist community services and teamsCare Planning and individualised Care planSupport to Self ManageEducation Programmes Annual ReviewSpecialist Medication reviews Anticipatory CareRemote monitoring via tele health where appropriate
Patients step up and down as risk profile changes
21% - 100%
Proactive Self Care Support and Management in Primary Care
Risk score recorded and reviewed annuallyActive Case FindingDisease Register Accurate diagnosisInformation PrescriptionsCare PlanningEducation relevant to patients needsDisease prevention andHealth promotion
HIGH RISK / Complexity
Low RISK / Complexity
Smoking Cessation, Health Promotion and Self Care
Admissions Avoidance
Public Health
Population wide Prevention
Disease awareness campaigns
Social marketing
Education
Health promotion
Schools
Workforce Development, Training and Education
Co-ordinated Social Care
Mid Nottinghamshire Integrated Model of Care for Long Term Conditions
Special Patient Notes / 24/7 Access to specialist support
Care Coordinator / Named Lead
1
2
3
4
Level
Slide20Systematisation of Self Care
Slide21Systemisation of Self Care and Care Planning
Support to increase patient involvement in their own care
Education
Confidence
Access to relevant support networks
Consultative care planning – we will do “with” and not “to”
“No decision about me without me”
Not just about giving information
Improving and enhancing provision of
carer
support, information and education
Inclusion of voluntary sector services to improve patient/carer support
Self Care is EVERYONES responsibility during
EVERY
patient contact
Slide22The evidence shows that it is the cumulative effect of each of these intervention and actions that makes a difference…..We have to do them all
Slide23What Have We Achieved to Date?
Slide2424
KPI Monitoring for PRISM – 10% reduction in emergency admissions for COPD, Diabetes and Heart Failure
North Team Go Live
West Team Go Live
Newark Team Go Live
Slide2525
Newark & Sherwood Emergency Admissions per 1,000 patients by PracticeMay 13 to July 13
Slide26What Have We Learned?
Stakeholder engagement is key and must not be underestimated – invest in the time up front
GP buy in critical – Financial support to get things going
Organisational sign up and commitment at senior level across all stakeholders
Needs to be CCG core business not a bolt on.
Dedicated project management – Needs to be someone's day ( and night!)
job
Investment in community services
Historic underinvestment meant we started from a low baseline
Staff training and skills development
Cultural as much as clinical
IT, Data and IG challenges – Expertise and investment required from day 1
Integrated Care on its own will not achieve the desired outcome
Whole system redesign is required to underpin the model including urgent care
Recognition that the outcomes wont necessarily be achieved immediately
Transformation
vs
QIPP
Slide27Benefits
In our Pilot, our admissions were reduced by 19%
Joint Visits – addressing medical and social issues
The team are contactable !!
Any problems can be resolved quicker, issues/problems are addressed that may previously have not been highlighted
Patients like it!
Slide28PRISM isn't a service – It’s a way of life !!
Slide29What Next?
Further development and training of the Integrated Care Teams and the MDT approachProactive in reach for facilitated discharge Emergency care pathways – working with OOHs providers to develop pathways to avoid unnecessary conveyanceEmbarking on “Year of Care” training for all clinicians Implementation of new self care strategyDevelopment and implementation of cancer pathways and supportJoining up the IT Scale up and roll out across mid Nottinghamshire as part of major Transformation Programme
Slide30The New Integrated Urgent & Proactive Care Model for Mid Nottinghamshire
Slide31Helping to shape future health and social care in Mid Nottinghamshire
COMMERCIAL IN CONFIDENCE
We
have a moral imperative to make the system fit for purpose for the changing demands of the population – people want to see joined up services and a system that is less complicated to
access, retaining universal access
Slide32Helping to shape future health and social care in Mid Nottinghamshire
What do we mean by integrated care ?
“
Care, which imposes the patient’s perspective as the organising principle of service delivery and makes redundant old supply-driven models of care provision. Integrated care enables health and social care provision that is flexible, personalised, and seamless
.”
COMMERCIAL IN CONFIDENCE
Slide33Helping to shape future health and social care in Mid Nottinghamshire
COMMERCIAL IN CONFIDENCE
Integration – a means to an end, not an end in itself
Integrated care must focus on those patients for whom current care provision is disjointed and
fragmented
Effective system leadership must
exist
The interaction between generalist and specialist clinicians must promote real clinical
integration
There must be integrated information
systems
Financial and non-financial incentives must be
aligned
Slide34Helping to shape future health and social care in Mid Nottinghamshire
COMMERCIAL IN CONFIDENCE
The consequences of being ambitious are less scary than not being ambitious enough….
Slide35Principles underpinning the design of the proactive and urgent care system
35
Significant interdependencies between proactive care and urgent care, hence the decision to develop a joint business case
None of the interventions can be considered or developed in isolation
Services will be available 7 days a week and, where necessary, 24/7
Care will be provided in a persons home wherever possible; the design focuses on reducing the need for admission to hospital/residential care, but, where this is required, seeks to expedite the return home as quickly as possible
Design spans health and social care, with joint funding and joint commissioning where appropriate
Utilises learning from elsewhere
The patient and the carer is at the centre of all design (Albert)
Provider “Blind”
Patients will receive / have access to the same care / services regardless of where they are domiciled ( ie care home vs Own Home )
Mental Health out of scope per se but all interventions designed with provision for interface
Slide36Care Navigator
Self care
Self Care Hub
Proactive and Urgent care model
Acute care
Care in the patient’s home
Crisis notification
Care navigation
Acute care
A&E/ MAU/ WARD
Single Front Door
Maintain independence
Healthy living & wellbeing
Acute Medical Emergency
PRISM plus
Specialist Intermediate Care Team
Discharge coordination
Proactive care
Crisis Response Team
Back door
MDTs
GP/
OoH
EMAS
Social Care
Determine
necessary care package and deploy services
Virtual wards / MDTs
Intermediate care in the home
Low level support
Enhanced support
Intensive support
Risk Stratification
Bedded Intermediate Care
Low level support
Enhanced support
Intensive support
A more responsive primary care service
Communicating effectively with the public
Urgent Care
Proactive care
Key:
Self Care
Away from the community
Towards community
SICT
Slide37Self Care
37
New Self Care Hub which will bring together all self-care activity and support across mid Nottinghamshire and act as a single point of access to relevant support for both healthcare professionals and patients.
It will enable patients to access information and practical support and advice to better manage their long term condition, to be signposted to self-care options, to make positive life style changes and learn essential skills.
The hub will be staffed by trained support workers overseen by a small management team with additional support provided by trained volunteers who will:
Work
as part of the Virtual Ward / Integrated Care teams to provide self-care support directly to patients in the community
Work
within the hub itself to provide telephone support, signposting, and information to patients and healthcare professionals.
The hub will also be used as a venue for specific training and education programmes for both patients and HCPs and also be utilised by other organisations wishing to provide or host self-care or care planning training and education events
Oversight and delivery of structured disease management education programmes
Slide38Virtual Ward MDT
38
Expansion of PRISM Virtual wards to 8 across Mid
Notts
Proactive care to
pts
at high risk of admission (identified via Devon Tool)
Rehab and
reablement
care for patients post crisis or post discharge
Work closely / aligned with Specialist Intermediate Care Team
Care planned and appropriate resources deployed within the team/s to meet the level of input / support required by individual patients dependent on their specific needs at any given point
Access to “fixed” beds for patients who require higher levels of support
Step Up / Step Down
MCH /
Fernwood
/ Existing Beds
Care Homes
Continual review to facilitate timely step down through the model
Interface with Mental Health Intermediate Care Services
Slide39Care navigator
39
Professional staff will phone when they have a patient with an urgent care need and they are looking for community alternatives to admission or to support a discharge from hospital or care home
Calls will be answered by a clinician (nurse, paramedic, SW) with rigorous call handling standards
The
service will operate from 8.00 - 22.00 each day as it is unlikely that effective navigation would be possible in the overnight period
A Directory of Services will support the service; this will include a capacity indicator for services as well as their criteria for access,
etc
Calls can be patched through to secondary care consultant staff for clinical discussions on the management of a patient
A GP will also be available for clinical discussion
By the end of the call the service will have agreed with the caller the package of care to be delivered and the timeframe within which it must be in place
Admin team will make necessary referrals with safety net procedure sin place to ensure that care plan is delivered as expected
Slide40Crisis Response
40
A function within the specialist intermediate care team
Currently mainstream services cannot always mobilise services quickly enough to maintain the person at home
A team of trained but unqualified staff who can respond to referrals and provide care within 2 hours; clinical input will be via the specialist intermediate care team
Available 24/7
Able to support patients who are currently at home as well those who may have attended A&E but do not require hospital admission
It is expected that:
90
% of patients will be transferred to the main specialist intermediate care service, other mainstream services or discharged within 3 days
100% of patients will be discharged or transferred within 7 days
Likely to be based at Kings Mill Hospital and Newark Hospital
Slide41Enhanced Intermediate Care Model
41
Intermediate care is the vehicle / enabler which will control the flow in and out of hospital and drive the right patient into the right place.
Three Key
Elements:
Admissions avoidance ( Proactive care and Step Up)
Support for early discharge
Rehabilitation and
Reablement
Evidence shows that patients have better outcomes when managed in their own homes –
esp
FOP’s
National policy direction to move away from fixed beds and increase provision of IC in the community
Care in the patients home as default with use of fixed beds only when level of support required precludes the option – (
ie
requires 24 hour nursing or medical supervision)
Move away from and balance current focus on step down to increase focus on step up to stop people getting to hospital in the first place
.
Slide42Specialist Intermediate Care Team working across three key areas
42
Front Door to support discharge to assess or admission plans
Discharge planning on admission and coordination and delivery of discharge on the wards
Provision of post discharge support / and care in the community including crisis response
Up to 14 days intensive rehab
Hand over to Virtual ward / MDTs for longer term support
Staff rotating across all three functions
Access to “fixed” beds for patients who cannot be managed in their own homes
MCH /
Fernwood
/ Existing IC Beds
Care Homes
Slide43Front door at A&E
43
Integrated booking in and triage systems between current PC24 and A&E service
Enhanced team at front door to include GP, specialist intermediate care, ANP for frail older people; increased consultant paediatrician presence
Signpost patients to other services following symptom relief and reassurance
Maximise see and treat
Maximise ambulatory care (upper quartile performance)
Enhanced function within specialist intermediate care to provide immediate
Slide44Fit with National Policy
44
Addresses the proposals in the national review of urgent and emergency care, phase 1 (with the exception of designation of A&E departments)
In line with the new enhanced service for the GMS contract
Design for intermediate care reflects recommendations made in National Audit of Intermediate Care 2013.
Slide4545
Benefit / Impact ( over 5 years)
Activity
Non-elective Admissions ( SFHT) Reduction of 19.5%
A&E Attendances (SFHT) Reduction of 15.1%
Occupied/Excess bed days (SFHT) Reduction of 12.6%
Non –elective readmissions ( all providers) Reduction of 10%
Demand for Long Term Residential care Reduction of 25%
Above activity delivers in line with Blueprint assumptions
Financial
Re- Provision costs slightly lower than Blueprint
Financial benefits being worked up and will be shared within formal business cases being presented to Governing Bodies in February 14.
Slide46Any Questions?
Thank You
Slide47For further information please contact:Jan BalmerAssociate Director – Integration and Unplanned Carejan.balmer@newarkandsherwoodccg.nhs.ukTel: 07734 296846
Transforming Care for People with Long Term Conditions
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