Transcript Slide 1

Early lessons from the Poole
Integrated Care Pilot
Matt Thomas
Consultant Physician
Dept of Medicine for the Elderly
Poole Hospital NHS Foundation Trust
Faithworks Wessex
Early lessons from the Poole
Integrated Care Pilot
Matt Thomas
Consultant Physician
Dept of Medicine for the Elderly
Poole Hospital NHS Foundation Trust
Faithworks Wessex
INTEGRATED CARE PILOT
PROPOSAL
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INTEGRATED CARE PILOT OVERVIEW
• The pilot will test a new model of GP locality integrated
dementia services.
• The ambition is to integrate not only with traditional health and
care agencies, but to become established and known within
the wider community to improve access for people with
memory impairment.
• Two new care services for people with memory loss and
dementia will be delivered by a joint multi-disciplinary team.
• This will provide high quality, person centred, specialist care.
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KEY FEATURES OF THE PROJECT:
• Aligns to the National Dementia Strategy and the associated
local dementia care pathway.
• Will deliver Early Intervention Services and a Specialist ‘Crisis
and Home Support Team’.
• Focuses on the locality of Westbourne.
• Targets ‘non-traditional’ hard to reach groups.
• Experiments with solutions to local challenges (e.g. LA
boundary issues, development of PBC, developing the market,
etc.).
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WHAT WILL BE INTEGRATED?
Patient
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ICP PROJECT LOCALITY AREA
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Population projections for Bournemouth and Poole, showing proportions
of 0 to 19 and over 65 year age groups 2006 to 2030
Percentage of total population
30
25
20
15
10
Bournemouth UA 0-19 years
Bournemouth UA 65+ years
Poole UA 0-19 years
Poole UA 65+ years
5
0
2006
2012
2018
2024
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2030
Age standardised hospital admission rates for all psychiatric
diagnoses, 2003-2005
700
Admissions per 100,000 persons
600
500
400
Bournemouth UA (persons)
Poole UA (persons)
Bournemouth and Poole PCT
England (persons)
300
200
100
0
1
2
3
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Relative Social Services Expendtiure by Category:
Bournemouth, Poole & All England 2006/07
Other Adult services
80%
Asylum seekers
Adult mental health (<65 yrs)
60%
Adult learning difficulties (<65)
40%
Adult disabilities (<65 yrs)
20%
Service strategy
Older People
Po
ol
e
Bo
ur
ne
m
ou
th
E
ng
la
nd
0%
Al
l
Percentage of total
100%
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Emergency Hospital Admissions by PCT 2005
(5M8) North Somerset PCT
(5QQ) Devon PCT
(TAL) Torbay Care Trust
(5QH) Gloucestershire PCT
(5QL) Somerset PCT
(5QK) Wiltshire PCT
(5QM) Dorset PCT
(5QP) Cornwall And Isles Of Scilly PCT
(5FL) Bath And North East Somerset PCT
(5F1) Plymouth Teaching PCT
(5K3) Swindon PCT
(5A3) South Gloucestershire PCT
(5QN) Bournemouth And Poole PCT
(5QJ) Bristol PCT
0
5000
10000
15000
20000
25000
Age-Standardised Rates Females 2005
Age-Standardised Rates Males 2005
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30000
LOCALITY GP PRACTICES INVOLVED
Case finding will take place using the vulnerable adults and carers
registers. Potential service users will be identified using a network
of organisations who come into contact with people living
independently in the community (e.g. community pharmacists,
emergency services, third sector, local services, etc.).
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DEMENTIA PATHWAY
Review 6 monthly
AD
confirmed
NICE not
met
COGNITIVE IMPAIRMENT
Memory
Clinic
GP/C of E
Physical
examinations
Investigations
MMSE
No unresolved
physical or
psychological
problems
MMSE >21
No unresolved
physical
problems but
with
psychological/
behavioural
problems
MMSE <21
Shared
Care as
per NICE
AD
confirmed
NICE met
YES
Non
Alzheimer’s
dementia
Probable AD?
NO and/or
other MH
problems
New psychological
or behavioural
problems with no
physical cause
CMHT for assessment and
monitoring as
appropriate
CRISIS AND DISCHARGE
SUPPORT TEAM*
Non-medical support team within
community to meet lifestyle needs of
the three identified groups of people
and their carers at any point on the
pathway
NICE
guidance
no longer
met
*taking referrals
from CWs in
Dementia Support
Team, acute Trusts
(elderly wards and
intermediate care
P
R
I
M
A
R
Y
C
A
R
E
W
I
T
H
M
A
N
A
G
E
M
E
N
T
P
L
A
N
AD diagnosed in CMHT
© P French 2008
OUTCOMES OF THE PILOT:
•
A fully integrated service aligned to the GP localities.
•
No boundaries between older people and older peoples mental
health services.
•
An integration model that moves beyond co-location of health and
social services staff into single line managed teams, with voluntary
sector staff.
•
A range of new locally based, low level interventions for people with
memory loss and their carers will be in place.
•
Interventions that can be accessed as a consequence of GP referral,
but also serve to signpost to GP’s, when memory loss is becoming
apparent.
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OUTCOMES OF THE PILOT:
• A single access point in a crisis to a fully integrated Crisis and
Home Support Team within their locality, which contains
specialist staff to respond specifically to the needs of people
with memory loss / dementia.
• Extended roles that stretch professional boundaries (e.g. health
care workers to undertake Mini Mental Evaluations - MMEs).
• Evidence of higher levels of confidence being expressed by
service users themselves, or their carers, of enabling them to
remain within their own home.
• A fully engaged / dementia aware community.
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PERFORMANCE MEASURES:
The project performance analyst will track:
• Financial measures (e.g. unit costs).
• Productivity (e.g. patients seen, response times).
• National health & social care KPIs (N125,etc).
• Benchmarking (vs. outcomes in the other 6 localities).
• Quality (audit, survey, complaints and compliments).
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PROJECT PLAN
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COST OF THE PILOT
PROJECT COSTS
FUNDING SOURCE
NO. OF STAFF
COST YEAR 1
COST YEAR 2
TOTAL COSTS
Back fill for Programme Management time
Performance Analyst
Back fill for clinicians advise project
TOTAL PROJECT COSTS
DoH
DoH
DoH
0.5
1
0.5
£25,000
£25,000
£30,000
£80,000
£25,000
£25,000
£30,000
£80,000
£50,000
£50,000
£60,000
£160,000
CRISIS & HOME SUPPORT TEAM COSTS
FUNDING SOURCE
NO. OF STAFF
COST YEAR 1
COST YEAR 2
TOTAL COSTS
NHS
NHS
NHS
Local Authority
NHS
NHS
NHS
NHS
NHS
0.1
1
2
1
5
1
N/A
N/A
N/A
£9,100
£36,000
£80,000
£35,000
£100,000
£25,000
£20,000
£20,000
£5,000
£330,100
£9,100
£36,000
£80,000
£35,000
£100,000
£25,000
£20,000
£20,000
£5,000
£330,100
£18,200
£72,000
£160,000
£70,000
£200,000
£50,000
£40,000
£40,000
£10,000
£660,200
FUNDING SOURCE
NO. OF STAFF
COST YEAR 1
COST YEAR 2
TOTAL COSTS
Local Authority
Local Authority
Volunteers
Volunteers
£18,000
£55,000
£73,000
£18,000
£55,000
£73,000
£36,000
£110,000
£146,000
£483,100
£483,100
£966,200
Psychiatrist
Band 7 Team Leader
Community Mental Health Nurse
Specialist Mental Health Social Worker
Specialist MH Intermediate Care Assistants
Dementia Care Advisor
Premises / utilities / telephones
Training / public education events
Staff travel
TOTAL CRISIS AND HOME SUPPORT TEAM COSTS
LOW LEVEL INTERVENTION COSTS
Memory cafes
Floating support services
TOTAL LOW LEVEL INTERVENTION COSTS
TOTAL PROJECT COSTS
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TEAM STRUCTURE / SERVICE FIT
POOLE LOCALITY MANAGER
PSYCHIATRIST
CONSULTANT
GERIATRICIAN
CONSULTANT
GERIATRICIAN
WESTBOURNE TEAM LEADER – C&HST
COMMUNITY
MENTAL HEALTH
NURSE x 2
SOCIAL
WORKER
WESTBOURNE TEAM LEADER - PICS
DEMENTIA
ADVISOR
CRISIS & HOME SUPPORT ASSISTANTS X 5
SOCIAL
WORKER
COMMUNITY
NURSE
INTERMEDIATE CARE ASSISTANTS
• RETHINK FLOATING SUPPORT
• ALZHEIMER'S SOCIETY
• MEMORY CAFÉ
• FAITHWORKS
• SIGNPOSTING SERVICES
GP SURGERIES
COMMUNITY PHARMACISTS / FIRE BRIGADE/ POLICE / AMBULANCE SERVICE / OTHER COMMUNITY CONTACTS
IMPLICATIONS FOR THE WORKFORCE
• Established local framework for delivering integrated services.
• TUPE & ‘Retention of Employment’ will not apply.
• There will be a partnership framework.
• This will be managed using a host budget (held by the NHS).
• Formal secondments & rotational posts will be used.
• Professional needs / support will be considered when deciding who the
employer will be of each role.
• Staff with the same role, may have different employers (e.g. Care
Assistants can either be on an LA employment contract or an NHS
contract) but T & C will be equitable.
• HR department will ensure legal and policy requirements are met.
• Approach approved by Tim Sands, Deputy Director Pensions Policy.
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DELIVERY MODEL
• The integrated team will have an office base in the Lilliput
surgery.
• Services will be delivered in community sites and in patients
own homes.
• GPs and patients will have a single referral telephone number.
• Emphasis on seamless service for patients (despite the
boundary issues with different local authority).
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CRISIS & HOME SUPPORT TEAM
The objectives of the team are that:
• To avoid unnecessary hospital admissions for people with a
mental health illness.
• To provide urgent response, short interventions to support
carers in crisis situations and to prevent carer breakdown
situations.
• To expedite discharges from hospital for people with a mental
health illness.
• Patients with memory loss/ dementia, receive person-centred
care.
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CRISIS & HOME SUPPORT TEAM
• Interventions usually for less than 2 weeks.
• Available between 7am and 10pm, 7 days a week.
• Resourced by community mental health nurses, specialist
trained crisis and home support assistants, a social worker and
medicines management.
• Will have access to consultant advice from a geriatrician and a
psychiatrist.
• Will be able to link into the generic services as appropriate.
• Will have pro-active crisis planning to support their work in
advance where possible.
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LOW LEVEL SUPPORT SERVICES
A dementia advisor will support people throughout their illness to:
• Provide advice to keep people active and well.
• To encourage the people to maintain the lifestyle, practices,
and choices that they had prior to having the disease to the
fullest extent possible.
• To draw up emergency plans in preparation for crisis
situations.
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LOW LEVEL SUPPORT SERVICES
• New signposting and support services for people with memory
loss and their carers provided through the creation of Dementia
Cafés funded by social services and operated by Alzheimer's
society.
• Reconfigured floating support services for people with memory
loss to give specific focus on the Westbourne locality. Rethink
team leader physically located within the team office and
working as part of the integrated team.
• Faith based and voluntary organisations within the locality
equipped to provide information and signpost people with
memory loss to the integrated team.
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PARTNERSHIP – LOCAL AUTHORITIES
• Integrated team supported by virtual team of Dorset Fire and
Rescue Services, Housing Services, Culture and Learning, Arts
Development.
• New well check service (commences July 09) to adopt specific
protocol for people with memory loss.
• Joint contract with Rethink for floating support services.
• Established pattern of joint working.
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PARTNERSHIP – THIRD SECTOR
• Third sector organisations i.e. Rethink, Alzheimer's Society and
Faithworks Wessex to form part of governance arrangements.
• Rethink team leader physically located within team office.
• Alzheimer's society dementia advisor located within team office.
• Operational single line management to operate across all
posts.
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PARTNERSHIP – COMMUNITY PHARMACY
• 7 Community pharmacies in the locality.
• Two will participate in the pilot.
• Westbourne and Canford Cliffs (main shopping areas).
• Will case find to signpost to the dementia advisor and to low
level services.
• Provides potential to expand the role of community
pharmacists further (e.g. undertaking MMSE tests, etc).
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PARTNERSHIPS TO BE DEVELOPED
Local shops
Libraries
Police
Ambulance
Fire
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PATIENT INVOLVEMENT
• Dedicated steering group of people with memory loss to be
established.
• Dedicated steering group of carers to be established.
• Both groups to be involved in service monitoring and ongoing
service design as per existing model operating in Poole
Intermediate Care Services.
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PROJECT GOVERNANCE
• Accountable Project Director - NHS Community Health
Services, Deputy Director.
• The Project Manager - will report to the Accountable Project
Director and to the Project Board.
• Locality Steering Group (LSG) - locality lay people,
professionals, commissioners and partners who will ensure
project objectives are met.
• Joint Commissioning Executive Group (JCEG) - will
consider joint strategic issues, which could impact the project.
• Business Manager / Performance Analyst - track /
monitor deliverables.
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OPERATIONAL GOVERNANCE
• Accountable Deputy Director.
• Regular operational and performance meetings with partners.
• Professional Line Management - of all staff and volunteers.
• Align to National Dementia Strategy / NSFs / LDP.
• Operational policies and procedures documented.
• Mental Capacity Act & Adult Protection training evidenced.
• Risk management procedures in place.
• Robust financial management.
• Performance monitoring.
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SUSTAINABILITY
• There are seven localities in Poole and Bournemouth. The pilot
can be commissioned / replicated in the other 6 sites.
• This approach has already been used to implement other
initiatives - e.g. Poole Intermediate Care Services and the
Bournemouth Community Assessment and Rehabilitation
Team).
• Financial stability / consistent performance of all partners.
• There are excellent relationships between the partners.
• PBC is developing and strengthening the relationships
between GPs and providers.
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THE PILOT WILL SUCCEED BECAUSE:
• It will have continuous user involvement from the outset
through the LSG.
• It extends a successful model already adopted within
intermediate care.
• It will be professionally project managed.
• The pilot fits within the local and national strategies.
• The outcomes are based on extensive research.
• The joint commissioners / PBC are supporting this.
• The professionalism / commitment of the clinicians and the
team.
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QUESTIONS?
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Lesson 1
• When is a pilot not a pilot?
– Enthusiasm can pre-empt assessment of
outcomes.
– Roll out regardless.
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Lesson 2
• A stitch in time saves nine
– Best plans are those where there is
engagement early on
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Lesson 3
• New methods of working don’t mean new
methods of diagnosis (EBM)
– Still need to use ICD 10
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Lesson 4
• Definitions
– Early diagnosis Vs first presentation of late
diagnosis
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Lesson 5
• Use the 3rd Sector
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Lesson 6
• Use what you have got
• PICS
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Case history 1
• Mrs H referred by GP to ICP re poor STM.
• Presenting problem: Lives alone. No family. Aware of
poor short term memory but not to true extent. Thought
she would sell flat as needed residential care as didn't
know how she would cope.
• Not known to any other professional
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• Pt Seen:
• Basic physical health screening completed, Full
dementia blood screen, urinalysis, BP, BM etc all NAD
• RMN completed full mental health assessment. (very
poor cognition identified)
• ICP ICAs in place daily re poor self care and promoting
independence
• ICP dementia support worker in place and initiating
weekly 1-1 engagement re life diary/history. (long term
involvement and future single point of contact)
• Referred to Rethink floating support re managing
bills/finances (in a muddle)
• Advised GP to refer to memory clinic with copy of
assessment re diagnosis (?Probable Alzhiemers) and
MMSE within NICE guidelines for consideration of
antidementia drugs.
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• Probable outcome: promoting independence and
hopefully remaining at home for longer as services in
place to monitor health and well being
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Case 2
• Mr S 93yr old man referred by GP to ICP RMN.
• Presenting problem: Wife died 2 days prior to referral.
Family concerned re poor STM and current managing of
personal care.
• Pt Seen:
• Basic physical health assessment, bloods etc all NAD
• Baseline MMSE 27/30. Suspicious ideas concerning
family and money evident. ?Acute grief reaction. Also
had just come to light his wife had left high amount of
money in her will he knew nothing about...?adding to
confusion and precipitating suspicious ideas
• Capacity assessment (although high scoring MMSE
completed due to presenting problems with memory
recall)
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• Decision specific to moving to residential care (pre
planned move to Jewish home that his sister resides in)
• Family had organised move but Mr S refusing to go until
affairs sorted out at home.
• Assessed has having capacity by SW and RMN
• Agreed to ICP ICA input to support current grief process
• Emergency OOH admission to PGH prior to ICA input
with chest pain.
• Physical tests NAD.
• RMN referred to in-pt psych team for review of mental
health due to familys current concerns re presentation
and him returning to his home (even with ICP ICA
support)
• Seen by in-pt psych and suspicious ideas noted but
unclear cause. Probable Acute grief. Discharged home
with planned ICP support.
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• Day following discharge phonecall to RMN from ICA to
say appearing physically unwell.
• Home visit immediately by PICS On call consultant and
RMN.
• Family also present and Mr S stating he wanted to go to
the residential home to be cared for. Made decision
himself and family arranged.
• Appeared sad and anxious.
• SW followed up in residential home. Suspicious ideas
remained re family and money. SW arranged to meet
with his solicitor 26-10-2009 and Mr S to go through his
money situation. Mr S aware and appeared to take on
board and SW felt he was reassured by this.
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• 24-10-2009. absconded from residential unit. Police
informed as missing person. Police found him at home
with a suicide note and an empty bottle of whisky
• Taken to PGH. seen and discharged same day.
• Readmitted 25-10-2009 with chest pain.
• RMN referred back to in-pt psych 26-10-2009 who re
assessed and was found to be psychotic and now
deemed sectionable. Now on antipsychotics. Deemed
significant suicide attempt but fortunately passed out
prior to drinking his pre-prepared cocktail of kitchen
cleaners.
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Case History 3
• Miss S referred by GP re poor STM
• No other professional involvement apart from
cardiologist
• Ongoing physical health problems re heart.
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• Full assessment by RMN
• 30/30 MMSE 92/100 Addenbrookes
• Engaged well and presented well until i asked her to do
a GDS. totally flummoxed by it and scored 7/15
(worthless, helpless, life not worth living etc)
• Symptoms all coincide with low mood, probably
precipitated by social isolation as fell out with her 2
friends last year and hasn't been out.
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•
•
•
•
•
Outcome
Referred to Age concern re social activities
Referred to Age concern re befriender
Referred to ICP memory support worker
RMN to monitor mood and behaviour and repeat GDS in
4 weeks and if no improvement liaise with GP re
antidepressants. If memory symptoms worsen GP to
consider CT and/or referral to CMHT re ?Frontal lobe
dementia
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