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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Slide1
Integrating Care across Mid Nottinghamshire
Transforming Care for People with Long Term Conditions and the Frail ElderlySlide2
Across Mid Nottinghamshire
The 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 Slide3
Quality 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 profilingSlide4
Patients 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 teamsIsolated – 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 999Overloaded, especially primary care and community servicesReactive – care is based around crisis managementSlide5
Our 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.
Improve 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 aheadSlide6
Our Partners
Sherwood Forest Hospitals Foundation TrustHealth Partnerships ( Community and Mental Health Services Provider)Nottinghamshire County Council
Newark and Sherwood District CouncilNewark and Sherwood CVS
Self Help NottinghamPatients
CarersSlide7
Integrating the management of cancer as a long term conditionSlide8
This is Albert
76 years oldEx MinerHeart Failure
DiabetesHypertensionHistory of alcohol abuse
He 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.Slide9Slide10
Principles 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 economyPersonalised care designed around the patients’ needs
Care planning and shared decision
making to become systematically embedded into every day practiceIncreased access to services around the clock and out of hoursRecognition of the need to invest and commitment to do soSlide11
Risk StratificationSlide12
Risk 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 admissionUtilised in 2 waysService Planning and commissioningPractice Level Patient IdentificationSlide13
Devon 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 Care
Psychological Support
Planned hospital admission , proactive in reach and facilitated discharge where needed
0.6-5%
Intensive disease / case management by specialist teams as part of the MDT
Telehealth
/
Telecare
Community Specialist Services and clinics with MDT support
Care Planning and individual personalised care plan
Planned 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 teams
Care Planning and individualised Care plan
Support to Self Manage
Education Programmes
Annual Review
Specialist Medication reviews
Anticipatory Care
Remote 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 annually
Active Case Finding
Disease Register
Accurate diagnosis
Information Prescriptions
Care Planning
Education relevant to patients needs
Disease prevention and
Health 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
LevelSlide14Slide15
Integrated CareSlide16
Locality Based Integrated Care Teams
3 x locality based Multi-disciplinary teams / Virtual Wards
North ward launched Dec12, West Ward March 13, Newark Ward April 13Each team comprising: ( all WTE posts)
Community MatronsDistrict Nurses
Occupational Therapist Physiotherapist
Mental Health Worker
Social Worker ( directly commissioned from LA by the CCG)Healthcare AssistantsVoluntary / Third Sector Workers – Part of the MDT Ward Coordinator/ ManagerSlide17
Underpinned by ………..
Specialist case management teams ( Level 3) for COPD, Heart Failure and Diabetes.Community based clinics ( CVD, COPD, Diabetes)
with commissioned consultant specialist supportCommunity 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) Slide18
GP
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
COPD
HF
Diabetes
Cancer
Dietetics
Tissue
Viability
Continence
Crisis Response / Rapid Intervention Service
Voluntary Services
Community Specialist Teams
Diabetes/ COPD/ Heart Failure/ Cancer
Level 3 Case Management
Step Up Step Down between level 3 and level 4 ( Virtual ward)
Linked to
Extended Team
Support across all localities
Virtual Ward
Core Team
Podiatry
EMAS/ CNCS/ OOHs
Intermediate Care
Access to & Support fromKey
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 TeamSlide19
Devon 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 Care
Psychological Support
Planned hospital admission , proactive in reach and facilitated discharge where needed
0.6-5%
Intensive disease / case management by specialist teams as part of the MDT
Telehealth
/
Telecare
Community Specialist Services and clinics with MDT support
Care Planning and individual personalised care plan
Planned 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 teams
Care Planning and individualised Care plan
Support to Self Manage
Education Programmes
Annual Review
Specialist Medication reviews
Anticipatory Care
Remote 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 annually
Active Case Finding
Disease Register
Accurate diagnosis
Information Prescriptions
Care Planning
Education relevant to patients needs
Disease prevention and
Health 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
LevelSlide20
Systematisation of Self CareSlide21
Systemisation of Self Care and Care Planning
Support to increase patient involvement in their own careEducation
ConfidenceAccess to relevant support networks
Consultative care planning – we will do “with” and not “to”“No decision about me without me”
Not just about giving informationImproving and enhancing provision of
carer
support, information and educationInclusion of voluntary sector services to improve patient/carer supportSelf Care is EVERYONES responsibility during EVERY patient contactSlide22
The evidence shows that it is the cumulative effect of
each of these intervention and actions that makes a difference…..We have to do them allSlide23
What Have We Achieved to Date?Slide24
24
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 LiveSlide25
25
Newark & Sherwood Emergency Admissions per 1,000 patients by Practice
May 13 to July 13Slide26
What Have We Learned?
Stakeholder engagement is key and must not be underestimated – invest in the time up frontGP 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 outcomeWhole system redesign is required to underpin the model including urgent care Recognition that the outcomes wont necessarily be achieved immediately
Transformation vs QIPPSlide27
BenefitsIn our Pilot, our admissions were reduced by 19%
Joint Visits – addressing medical and social issuesThe team are contactable !!Any problems can be resolved quicker, issues/problems are addressed that may previously have not been highlightedPatients like it!Slide28
PRISM isn't a service – It’s a way of life !!Slide29
What Next?Further development and training of the Integrated Care Teams and the MDT approach
Proactive 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 ProgrammeSlide30
The New Integrated Urgent & Proactive Care Model for Mid NottinghamshireSlide31
Helping 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 accessSlide32
Helping 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 CONFIDENCESlide33
Helping 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
alignedSlide34
Helping 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….Slide35
Principles 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 Slide36
Care 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
SICTSlide37
Self 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 communityWork
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 Slide38
Virtual 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 dischargeWork 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 supportStep 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 Slide39
Care 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, etcCalls 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 expectedSlide40
Crisis 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 admissionIt is expected that:
90% of patients will be transferred to the main specialist intermediate care service, other mainstream services or discharged within 3 days100% of patients will be discharged or transferred within 7 days
Likely to be based at Kings Mill Hospital and Newark HospitalSlide41
Enhanced 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
.Slide42
Specialist 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 supportStaff rotating across all three functions
Access to “fixed” beds for patients who cannot be managed in their own homesMCH / Fernwood/ Existing IC Beds
Care HomesSlide43
Front 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 Slide44
Fit 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.Slide45
45
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.Slide46
Any Questions?Thank YouSlide47
For further information please contact:Jan Balmer
Associate Director – Integration and Unplanned Carejan.balmer@newarkandsherwoodccg.nhs.uk
Tel: 07734 296846
Transforming Care for People with Long Term Conditions