Transcript Slide 1
Intermediate Care
Programme and Telehealth
East Lancashire
Susan Warburton MSc, RGN
Head of Community Services
Key Facts
East Lancashire population 376,000
Diverse
- geography/urban/rural
- population/ethnic
- prosperity/poverty
By 2015 > 65 years increase by 17.3% in East Lancashire
Incidence rate dementia increasing
Prevalence of chronic diseases > 65 years increasing
High impact areas
•
•
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CVD
COPD
Diabetes
Dementia
LCC spend £13 million on intermediate care related services
NHS East Lancashire spend £26.4 million
Outcomes of that spend poor/multiple duplication of service
70% of existing health and social care costs are used on people with LTC
60% increase in the number of people with more than one long-term condition within the next decade
Savings required of £56 million over 3 years to balance the books
Every GP and health and social care practitioner knows that most of their time is spent caring for people with longterm conditions
Ignoring the problem is not an option!
Strategic Direction
Supporting People with LTC’s (DH 2005)highlighted the need to provide proactive
care in the community to keep people managing their LTC’s
Our Health, Our Care, Our Say (DH 2006)
Meeting Patients Needs programme committed to provide Care Closer to Home
(2007) – LTC care stream redesigning pathways
Putting People First (DH 2007)
Commissioning Strategic Plan 2008 has intermediate care in the community as a high
level priority
Transitional Care Project commissioned in 2009 joint endeavour with LCC/ELPCT
Significant evidence base that care closer to home provides quality of outcome at
reduced cost
Transforming Community Services (2010)
Operating Framework 2011
Vision for Adult Social Care (DH 2010)
Intermediate Care-Half way Home (DH 2009)
Ready to Go (DH 2010)
Intermediate care programme reflects the commissioning intentions of GP
commissioners to commission integrated community services that support care closer
to home or when possible in the home
Integrated working with LCC and other partners to achieve the seamless pathways of
care together with the inherent cost benefit
Case management model - TCS
Evidence
Integrated working between health, social care and
partners reduce bed usage and emergency admissions
(Torbay)
SPA-good communications-integrated records,
involvement of VCFS (Third Age) prevent readmissions
and improve outcomes for older people (Cumbria)
Independent sector can bring innovation, investment and
transformation in integrated service provision (Serco)
Virtual wards – hospital avoidance (Wandsworth)
Same day access to primary care, easy access to
specialist, the use of IT and access to test results reduce
demand and improve outcomes (Brent)
What Patients Tell Us!
They want to be supported and their care needs
managed in their own home or as close to their
homes/community as possible
They are concerned that community services will not be
able to provide enough support to enable them to be
properly supported to self manage their condition
As their condition evolves they are concerned about their
options and feel that hospital is a safe place hence
increasing hospitalisation of ASC
Social isolation is mentioned by older people and for
those who are disabled by long term conditions as a
concern – fear of staying at home
LTC QIPP
Improving
outcomes for those with a LTC
by delivering local, efficient, patient
focused services
Responsive management of conditions
that reduce the need for costly
hospitalisation
LTC QIPP
RISK PROFILING - Using risk profiling to ensure that teams understand the
needs of their population and manage those at risk. Will allow for
interventions to be targeted and prioritised.
INTEGRATED CARE TEAMS - The creation of integrated health and social
care teams based around a locality (or neighbourhood). These generic
teams pull in specialist services when necessary, but treat a patient
holistically instead of the condition. Joined up, productive care
SELF CARE / SHARED DECISION MAKING – Seeing patients as experts
in their condition and empowering them to seek the information, care and
support they need when they need it.
‘No decision about me without me’
All have to be in place to get results!
East Lancashire’s Intermediate Care
Vision
Patient Centred Care
Generic Workforce
Health and Social Care
- Robust Clinical Leadership
- Multi-DisciplinaryTeams
- Greater use of technology
- Shared information systems
- Developing community services
24/7 365 days
- Joint education and training
including the 3rd Sector
Single Assessments
Outcome based assessments
Personal Care Plans
Self Management (LTC)
Personal Health/Social Care Budgets
Personal Sanctuary (EOL)
Long term Care Coordination
PATIENT
Improved Communication
Patient & Public Involvement
Social Marketing
Working with 3rd Sector
Demand Management
Managing patient flows
back to community
(i.e. referring patients
back to the community
sooner)
Preventing Admissions
and readmissions
Measurable Outcomes
Reduced numbers of admissions
Reduced lengths of stays
Improved Patient Outcomes
Improved Patient and Service
Experience
Different Financial Models
Pathway Redesign Areas
Urgent care – timely and effective discharge
Urgent care – admission avoidance
Long term conditions (including Mental Health)
End of Life
Planned Care
Rehabilitation and Reablement
Funding
Additional funding from the DH to support
rehabilitation/reablement
Notification that from 2012 acute providers will
be responsible for care 30 days post discharge
Requirement to work in a collaborative manner
with LCC and providers to ensure integration of
pathways for service users, innovation in deliver
of care and development of responsive services
Rehab/Reablement Funding
Rep/NR
2010/11
£m
2011/12
£m
2012/13
£m
Purpose of funding
Development of post
discharge support
R
0.55
1.18
2.36
Reduce avoidable
admissions, bolster
community capacity, and
preventative services. For
local determination
To support social care
services
NR
1.22
4.87
4.67
Funding must be transferred
to LCC. Plans for spend
must be agreed with health
before transfer of funds
Readmissions
NR
0
0.58
0
Indicative figure that will be
retained by acute provider in
2012/13 . Hospital will
responsibility 30 days
following discharge.
Progress to date
Joint business case produced with LCC –vision
for future integration
Event November 2010 – GP Commissioners
Shaping the Future
Commissioning intentions stated 11/12 contract
notice given (rehab)
Governance structures in place with partners
Work streams established at East Lancs level –
joint project management
Redesign of integrated therapy with reablement
being undertaken
Continued
Redesign of community nursing service
Virtual ward pilot programme in Pendle in
collaboration with LCC-now rolling out across
East Lancashire
Cost benefit analysis/business case being
worked up
LCC redesigned residential rehabilitation to
include night time support and extra health
support e.g. GP assessment
Continued
Joint Commissioning Strategy for Dementia produced
Integrated strategy for End of Life care developed by
EOL project group
LCC Crisis support services re-modelled to
provide consistent service delivery across EL
Tested the use of independent sector
intermediate care beds
ICAT commissioned
EMIS web roll out will be completed by March
2013
Telemedicine/telehealth project to commence
Continued
Needs assessment of patients undertaken in
community hospitals triangulated with other data
Review of extra care accommodation and
intermediate care support available
Beginning to review and look at options for new
models for intermediate care in the community
i.e. different housing models – Belong
Business case being drawn up around the
support of those with dementia (LTC) in the
community
Virtual Ward
Pilot programme – 12 months Dec 2010
Whole system approach needed to shift care
delivery- working with partners
3 levels
Promotion of self care and condition
management e.g. COPD care bundle
Encouragement to live more independently at
home
Redesign in the way community services are
delivered
What did we do?
Pilot in Pendle
Invested in community equipment response
Invested in social workers
Invested in therapy locum support
Invested time in communication with
practices/LCC provider
Community nursing staff redesign to change
focus – more responsive
Daily ward rounds - teleconference
Evaluation
Provider staffing costs
Details of GP/OOH call out
Prescribing costs/medicines management
Use of equipment
Cost of diagnostics
Therapy input
Detailed activity assumptions and case mix
Costs across the pathway into social care
Patient experience
Telehealth Project
Project
being developed in collaboration
with InTechnology- 2 year pilot
Project began in May 2012 and will begin
to recruit patients in September 2012
Focus will be initially on the COPD
pathway to trial the project – 200 patients
per year
Dedicated project manager
The Project
Consultancy support
Training and Education of staff
Web enabled portal for staff and patients-self
management support
Completely managed service supported by NHS
Direct
Development of pathways
7 days per week
Linked to virtual ward-side ward
Patients risk profiled to identify appropriate
patients – level 2-3 patients
Outcome
Allow the individual to develop the knowledge
and skills to manage condition
Allow health professionals to target their efforts
where required
Improve patient experience of health
care/increase confidence
Reduce health inequity by providing a different
approach
Reduce hospitalisation by proactive
interventions
Slowing disease progression due to proactive
connected management
Next Steps
Continue to work with partners to build on the strong
foundations that we have put down over the past 2 years
Work with LCC and partners in the alignment of telecare
to current intermediate care projects
Further develop the preventative and self management
community infrastructure e.g. hand rails, slipper
exchange
Further develop collaborations with housing associations
and others to promote improvement in housing stock that
will meet the needs of the aging population thus
supporting care closer to home vision
Continued partnership working with VCFS and other
partners e.g. hospital aftercare service (Age UK)
THANK YOU !
Susan Warburton
Head of Community Services
East Lancashire PCT
Tel:01282 644881
Email: [email protected]