Integrating Care across Mid Nottinghamshire

Integrating Care across Mid Nottinghamshire

Transforming Care for People with Long Term Conditions and the Frail Elderly

Across 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

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 profiling

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 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

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.

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

Our 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

Integrating the management of cancer as a long term condition

This 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.

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 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

Risk Stratification

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 admission

Utilised in 2 ways

Service Planning and commissioning

Practice Level Patient Identification

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 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

Integrated Care

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 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

Underpinned 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)

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 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

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 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

Systematisation of Self Care

Systemisation 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

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 all

What Have We Achieved to Date?

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 Live

25

Newark & Sherwood Emergency Admissions per 1,000 patients by PracticeMay 13 to July 13

What 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

Benefits

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!

PRISM isn't a service – It’s a way of life !!

What 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

The New Integrated Urgent & Proactive Care Model for Mid Nottinghamshire

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 access

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 CONFIDENCE

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

aligned

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….

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

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

SICT

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 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

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 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

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,

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

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 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

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

.

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 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

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

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.

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.

Any Questions?

Thank You

For 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