Transcript Document

Multimorbidity Action Plan
Dr Anne Hendry
Dr Frances Elliot
Enabling People to Live Well
• “Making care truly person-centred
requires radically different ways of
thinking…..
• If we are to see truly collaborative
approaches to healthcare, we will
need not only those change
mechanisms with which we are
familiar..
• But also conversation and space
that enables people to
understand, reflect upon and
reconsider their purpose,
attitudes, roles and relationships“
Top Ten Improvement Actions
LTC Collaborative
Level 3
Complex Highly
Case/Care complex
Management
Risk prediction in primary care
Case Management
Anticipatory Care Plans
Specialist
(Condition)
Management
Support for Self Management
Level 2
High risk
Intermediate care
Telehealth and Telecare
Reablement and Rehabilitation
Medicine reconciliation & pharmaceutical care
Self
Management
Level 1
70-80% of
pop
Reduction in delayed discharge
Hospital pathways for frailty and delirium
LTC Collaborative 2008 – 2011
Boards delivered 14% reduction in bed day rate for COPD, Asthma, CHD and
Diabetes between 2006/07 – 2010/11
Multimorbidity – 3 Workstreams
1. Micro system - Care planning and consultations that help people to have control
over their conditions, care and support and achieve their personal outcomes
• Build on the PPHWB and ACP/ polypharmacy work;
• Adopt House of Care in General practice
2. Meso system - Technology enabled care and support that builds on community
assets to promote independence, wellbeing and resilience
• Spread Improving LINKS, ALISS and community facing primary care;
• Scale up 3 THC priorities - Lite touch remote monitoring ; Apps for self
management; virtual consultations
3. Whole system pathways that are designed around Multimorbidity and to reduce
health inequalities
• Develop integrated locality arrangements that engage MCNs and deliver care
coordinated across the whole pathway by a lead professional / named person
•
Visible adaptive leadership and a coherent research, innovation and improvement
infrastructure that drives excellence in Integrated Care for Multimorbidity
New Paradigm for Measurement
Integrated care
Intermediate care:
NHS rehab / enablement
at home/day hospital
Care management/
anticipatory care:
Primary Care:
Long term conditions
care planning
Community nursing
NHS Self-Management Support:
Mental Health:
Self-management programmes/
psychological interventions
Recovery support
Data about individuals
Locality data
Partnership / LA / Board data
(local measurement)
Partnership / LA /
Board outcomes &
indicators (national
focus)
Catriona
Hayes
National
Performance
Framework &
other key
national
indicators
Draft measurement framework: Multiple morbidity
Level
Examples of measurement
Individuals
Improvement in Personal outcomes; uptake of Self Directed
Support; Anticipatory Care Plans; KIS accessed
Localities
Aggregated personal outcomes data for commissioning;
Locality information to understand need and target support;
General Practice data ; user feedback; improvement of process;
Demand and capacity data for planning to support client needs;
Workforce and financial resources
Partnership / LA /
Board (local report)
Aggregated and comparative locality data to understand overall
performance, variation and inequalities within the partnership
Partnership / LA /
Board (nationally
available)
National patient experience surveys (including integration
indicators); hospital activity and delays; QOF data
National
Self-assessed General Health; Mental wellbeing; Support for
people with care needs; Hospital activity and delays;
Healthcare experience; Physical activity
Lessons from RCOP
• Takes time to reach consensus and build will across multiple partner
organisations
• Significant lead time for partnerships to test innovations, particularly
statutory organisations
• Pressured to get maximum gain from a one year £100M Integrated
Care Fund
• Urgent need to accelerate organisational readiness in the next 6
months and increase capability to drive the MM actions and deliver
outcomes
• ‘Resource light collaborative’ - eg Dementia Improvement Programme
• Programme management support required to engage partnerships,
secure traction and ensure coherence with other improvement work
• Information resource required to develop and support use of a
meaningful measurement framework