Transcript Slide 1

Seamless pathways for longterm conditions:
The Integrated Care Initiative
Dr Peter Hammond
Consultant Physician
Clinical Director, Integrated Care
What is a long-term condition?
• A long term condition is any medical
condition that cannot currently be cured
but can be managed with the use of
medication and/or other therapies.
• This is in contrast to acute conditions
which typically have a finite duration such
as a respiratory infection, an inguinal
hernia or a mild episode of depression.
Royal College of General Practitioners
Long-term conditions
• 15 million people at least one LTC (2012)
projected at 20 million by 2025
• Accounts for 70% of NHS expenditure
• 68% OP and ED appointments; 77% of
inpatient bed days
• Person with 3 LTC: annual cost to health
and social care £8000 on average
NHS and Social Care LTC Model
“The NHS, working with local authorities and the new health and wellbeing
boards, needs to be much better at providing a service that appropriately
supports these patients’ needs and helps them to manage their own
conditions.
Better management of their own conditions by patients themselves will
mean fewer hospital visits and lower costs to the NHS overall, and more
community-based care, including care delivered in people’s homes.”
NHS Call to Action, July 2013
“Older people with long-term conditions want good primary care,
community care and social care, joined up around them
regardless of clinical categories or structural splits
between healthcare on one hand and social care on the other.
They want good out-of-hours services,
so that their conditions can be managed in their own homes
and prevented from deteriorating, and to make it possible
to minimise upsetting, disruptive and expensive episodes in hospital.
This is not the system we have.”
Ready for Ageing?
House of Lords select committee
report 2012-13
What is integrated care?
NHS Future Forum 2012
• Integration should be defined around the patient, not the
system – outcomes, incentives and system rules (ie.
competition and choice) need to be aligned accordingly.
• Health and wellbeing boards should drive local
integration – through a whole-population, strategic
approach that addresses local priorities.
• Local commissioners and providers should be given
freedom and flexibility to ‘get on and do’ – through
flexing payment flows and enabling planning over a
longer term.
Integrated Care
means
Person-Centred Co-ordinated
Care
National Voices: A Narrative for Personcentred Co-ordinated Care 2013
The House of Care
“A seamless service”
Self care
and
independent living
Comprehensive
Integrated
Higher quality
Affordable
Community
based
care
Hospital / Specialist
care
Wide-ranging health services, from supporting prevention
and self-care, through support in the community, to
specialist care.
All health and social care services working closely together to
provide one seamless service
Better quality care, with more lives saved and more people
returned to full health
A service that is affordable in the years to come
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Diabetes Care:
an integrated care pilot
Why Diabetes?
• £725 million/year spent on diabetes medication:
8.4% total NHS drugs spend
• £600 million extra is spent on in-patient care for
people with diabetes
• People with diabetes account for 15-20% patient
bed days
Why Diabetes?
• Well-developed good quality primary and
secondary care services, with active local
diabetes network
BUT
• Working in “silos” – good working relationships
but limited integration at all levels:
– Patient focus
– Information sharing
– Knowledge-management
Integrated model - strengths
• Patient-centred
– Meaningful consultation; Personal agendas
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•
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Seamless patient movement through service
Practice self-assessment
Integrated patient record
Integrated knowledge management
Managed clinical network
Partnership working as opposed to devolution;
secondary care providing community-based services
• Different funding arrangements
Patient Pathway
Referred back to GP
practice
GP to decide what level of
care is required
GP unable to provide
care
Two-way referral system
TRIAGE
at Single Point
Access (SPA)
at LTC Centre
MDT Intermediate
Care, including
transitional and
rapid access clinics:
Education
New Type 2
DAFNE
Insulin Dose
Adjustment
Post Insulin Initiation
CSII therapy
Consultant / GPwSI
DSN
Dietician
Podiatrist
Psychologist
Can refer to SPA for services not available in
practice e.g. education, podiatry, retinal
screening, weight management
Secondary
Care
At Risk Foot Clinic
DSN
Podiatrist
Consultant / GPwSI
Patient with Diabetes
GP services providing routine
diabetes care
A&E or Emergency GP
Admission
Single referral form
to
Weight Management
Programme
Treatment
Pharmacy-Led
Cardiovascular
Risk Clinic
Housebound
Patients
Residential &/or
Nursing Home
Housebound
End of Life /
Palliative Care
Prison
District Nurse /
Community Matron
reviews supported by
DISC Team
Inpatient Assessment &
Management
Patient Groups within OP
services:
Paediatrics
Renal inc. dialysis pts
Complex Patients
CSII therapy
Retinopathy treatment
Joint Diabetic Foot
Optimise Pre-op surg
End of life patients
Urgent OP Referral Access
Foot Ulcers
Gestational
Pregnancy/Pre-conception
complete
Retinal Photography
Service
Evidence of Complications or
Management not possible in
Primary Care
For MDT meeting
review
Referral to secondary care
Primary Care / General Practice
Diabetes Intermediate Specialist Community Team
COMMUNICATION
Secondary Care
Equality of Access
P
GP practices
Inc:
Practice Nurses
District Nurses
Community Matrons
Out of Hrs Service
- Point of access
- Triage & Assessment
- Prevention
- Screening
- Risk Assessment
- Public Health
- Education
- Self-management
- POCT
- N/H & R/H
- Housebound Pts:
Prisons
Mental Health
Learning Difficulties
End of Life
I
Workplace
Occupational Health
School Nurses
- Public Health
- Prevention
- Risk Assessment
- Education
- Awareness
Pharmacies
Enhanced Services
- Prevention
- Screening
- POCT
- BP assessment
- Education Inc.Training on
blood glucose monitoring
- Empower patient through
self-management
e.g. troubleshooting BG
meter issues
- Risk Assessment
- Referral to GP as necessary
for Triage
LTC Centre
(Harrogate)
Pilot Sites to cover
rural population
e.g. Ripon, B’bridge,
The Dales, Skipton
- Housebound Pts:
Prisons
Mental Health
Learning Difficulties
End of Life
- Support of N/H & R/H
- Retinal Photography
- At Risk Foot
- CV Risk Pharmacist Clinic
- Education
- Interm. Care team Clinic
- Weight Management
programme
- Rapid Access Clinic
S
- Children
- Transition Care
- CSII Assessment
and Initiation
- InPt Diabetes
Team
- Dialysis Pts
- Retinopathy
Treatment
- Joint Diabetic
Foot Clinic
- Pregnancy inc
Gestational
- Complex Pts
- Optimise pre-op
surgery
- End of Life pts
(through Macmillan
Dales Unit)
Code:
Green – Primary Care
Orange – Intermediate Care
Children
Complex LT conditions
Gestational and pregnancy
Inpatient Hospital Care
CSII initiation and unstable patients
Active Diabetic Foot Complications
Pre-op surgical patients
Dialysis patients
End of Life patients
Problem patients
Unstable diabetes
LT complications
Stable CSII patients
High risk foot assessment
Structured education
Retinal photography
Housebound patients
End of life patients
Transition Clinic
T1 – management of stable patients
BD or Basal Bolus insulin
initiation for T2
Insulin Regimen Changes
Insulin Initiation – once daily
T2 on Insulin
Prevention
Screening
IGT
T2 on diet or OADs
Education
Housebound Patients
End of Life Patients
Practice Level Management
Practice
Level 1
Practice
Level 2
Practice
Level 3
Practice
Level 4
Red – Secondary Care
LTC – pathways of care
Pathways of care
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NYYPCT initiative
Facilitated by Ernst and Young
Stimulus to integrate telehealth
Representation from PCT, secondary and
primary care providers across NY
• Consensus pathway to define practice
across NY
Diabetes Care Pathway: Adult Type 2 Diabetes
Patient identified through
primary or secondary care
screening
Patient presents with
symptoms of diabetes
Patient identified through
opportunistic testing (history,
high BP)
Patient referred by Optician
Blood glucose, HbA1c and
urine tests
Patient self-refers following
blood glucose test at local
pharmacy
Consider alternative
diagnosis, eg.
classification of
diabetes as genetic
causes e.g. MODY,
secondary causes, or
Type 1
Patient is acutely
unwell (possible Type
1 diagnosis) – refer
urgently to acute
hospital
Diabetes confirmed, Type 2
suspected
Are there any immediate indications for
referral to secondary care?
Yes
Indications for referral
Patient has complications
Foot
Cardiovasproblems
cular
Refer to joint diabetes
and obstetrics clinic for
all patients pregnant or
considering pregnancy
now or at a later stage
Renal
disease
Visual
impairment
No
Management of patient in primary care: Produce
care plan and negotiate patient goals (including
cholesterol, blood pressure and HbA1c targets)
Introduce to local
Diabetes UK group
Standard referrals for all patients
Offer exercise on
prescription or other
exercise opportunities /
No
advice
Offer all patients full-length
structured education
course (DESMOND or
equivalent)
Refer all patients to
retinal screening
pathway
Yes
Offer all smokers
cessation support
Yes
Would the
patient benefit from a delay
before commencing medication
to allow a period of diet and
lifestyle adjustment?
GP/Practice Nurse reinforces education
and supports patient in new diet and
exercise regime for three months
Can patient be discharged to primary
care for initial diabetes management?
No
Women who are pregnant and a small
proportion of patients who have unstable
complications will be managed by
specialist team, including receiving
standard advice and referrals
No
Immediately begin oral drug
therapy and titrate up alongside
diet and lifestyle adjustment
Yes
Would the
patient benefit from a delay
before commencing medication
to allow a period of diet and
lifestyle adjustment?
GP/Practice Nurse reinforces education
and supports patient in new diet and
exercise regime for three months
No
Immediately begin oral drug
therapy and titrate up alongside
diet and lifestyle adjustment
Retest HbA1c after three months.
If target not reached begin/increase drug therapy
Introduce insulin as necessary
Initiate insulin in primary care (refer patient to
nominated GP surgery if not able to provide treatment in
patient’s own surgery)
Self-monitoring of blood
glucose should be
considered for patients
where hypoglycaemia is a
risk (see PCT guidelines)
Refer to secondary care or
alternative service where
incretin or insulin therapy is
required and cannot be initiated
by primary care
For patients with raised BMI consider use of incretin
therapies (GLP-1 – see CG87) and seek specialist
advice as to suitability
Discharge to primary care
where appropriate
For patients who are unable to inject
or monitor own blood sugars,
Community Nursing service can
provide support
Primary care – Perform regular reviews and test
HbA1c every 3-12 months depending on patient
condition
Give lifestyle and nutrition advice as part of review
Review care plan and renegotiate as necessary
Check for complications and frequency of
hypoglycaemic epidodes
Review medication including up-titration/withdrawal
of drugs
Is the patient adequately
managing their diabetes,
complications and
comorbidities?
Maintain
process of
annual care
plan review
throughout
lifetime
No
Yes
Go to glycaemic
emergency pathway
Yes
Has this led to a
glycaemic emergency?
Indications for referral and treatment/support provided
Patient has diabetic complications
Foot
problems
Renal
disease
Cardiovascular
Visual
impairment
Refer to relevant specialist e.g. Podiatrist,
Opthalmologist for treatment of complications
Patient is pregnant or considering pregnancy
Refer to joint diabetes and obstetrics clinic
Patient has inadequate control of diabetes, and/or change
in lifestyle that for example leads to change in eating
patterns or exercise levels
Refer to specialist diabetes team or
intermediate care clinic (e.g. Mowbray Sq) to
support change to drug regimen. Consider
referral for further education e.g. DESMOND
Patient experiences frequent hypoglycaemic episodes or
hypoglycaemia unawareness
Refer to specialist diabetes team or
intermediate care clinic (e.g. Mowbray Sq) to
support change to drug regimen
Patient has inadequate control due to poor compliance,
anxiety or depression
Refer to clinical psychologist/counselling
service for psychological support (for both
patient and carer where appropriate)
Patient has comorbidity of COPD and/or heart failure that is
adversely impacting their diabetes or vice versa
Consider referral for telehealth monitoring
Patient continues to have inadequate control despite
optimisation of multiple treatment types
Consider referral for telehealth monitoring
Patient has inadequate control on insulin therapy
Refer to specialist diabetes team for
optimisation of insulin therapy (possible use of
incretins). Consider continuous glucose
monitoring
No
Locality diabetes care - progress
• Successes
– QoF
– Intermediate clinics
• MDT
• Admission avoidance
• Patient engagement
• Challenges
– Prescribing targets
– Capacity
• Education
• Injectable therapy
– Individualised therapy
Implementation - challenges
• Stakeholder engagement
• Finances – ensure not a barrier to development
• Staffing – ensure efficient use of human
resources
• Location – ensure adequately address access
issues
• Dissemination – models developed and lessons
learned need to inform other service
developments
• Technology
The Future Hospital Commission
Hospitals on the edge?
In September 2012, the RCP highlighted the
challenges facing hospitals:
•rising clinical demands (37% rise in emergency
admissions, fewer beds)
•changing needs (more older people, with multiple, complex
conditions)
•fragmented care (patients being moved around the system with little
continuity)
•out-of-hours care breakdown (higher mortality at
weekends and fewer senior staff)
•medical workforce crisis (increased workload, recruitment
problems in emergency and general medicine)
Future Hospital’s aim
Identify a new way of designing and delivering
hospital services that:
•Comes to the patient
•Is coordinated around patients’ needs (including
for patients with multiple conditions)
•Is organised over seven days
•Reaches beyond hospital walls
•Values patient experience as much as clinical
outcome
•Delivers clear lines of responsibility for patient
care
A new model of hospital care
Medical Division
-
Covers all medical services and teams
Remit from hospital into community
Led by Chief of Medicine
Acute Care Hub
Part of Medical Division
Covers assessment and initial management
of acutely ill patients (focus: first 48 hours)
Overseen by acute care coordinator
Clinical Coordination
Centre
-Operational control centre for medical services
-All data on patients – needs and real time
monitoring
-All data on capacity and resources
New Model of Clinical Care
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Hospital services that operate across the health economy
Seven-day services in hospital
Seven-day services in the community
Continuity of care as the norm
Stable medical teams in all acute and ward settings, focused on
the whole care of the patient
Focus on alternatives to acute admission and supporting patients
to leave hospital
Care delivered by specialist teams in community settings
Holistic care of vulnerable patients
Information is used to support care and measure success:
Clinical records will be patient-focused
Information will be held in a single electronic patient record
Common record standards
Information viewable in both the hospital and community
Traditional Model
Integrated health model
Integrated care: the LGA* view
• The concept of integrated care has developed as a
response to fragmented delivery of health and social
care services in some parts of the current health and
care system.
• The Better Care Fund (BCF) is one of a number of
initiatives through which the integration of care and
support will be achieved.
*Local Government Association
The challenge
• Develop more flexible, efficient pathways
of care across health and social care
• Less reliance on condition-specific
pathways of care
• Be able to adapt care to the individual
patient’s needs
A Health and Social Care model?
“The Patient Hub”