Transcript Integrated Care Teams QIPP Long Term Conditions

‘Integrated Care Teams’
QIPP Long Term Conditions
Dr J John
National Clinical Associate in LTC/QIPP
Department of Health
19th July 2012
Kent and Medway LTC Programme
Statistics
Long term
conditions
represent…
70% of health
and care
spend
The average
annual health
cost…
170,000 people
die prematurely of
long-term
conditions each
year
Significant
variation across
PCTs exists in
emergency
hospital use
The Case for Change
252% rise in over 65 year olds by 2050
188% rise just in Diabetes by 2050
60% increase in the number of patients
with multiple LTCs by 2013
The Case for Change
Pay: 3+
Long Term Conditions
Amount in Words: Nineteen Billion Pounds
Date:
2011
Current
Spend
2011
£19,000,000,000
Signed:
No health care
system is
sustainable in
the face of this
tsunami of
need
__________
Projected Spend 2016
Pay: 3+
Long Term Conditions
Amount in Words:
Date:
2016
Twenty Six Billion Pounds
£26,000,000,000
Signed:
___________
The systems
perspective
Too many admissions
& readmissions
The patient
perspective
High Anxiety
Low levels of confidence in
managing own health
Too much activity in
secondary care
Low levels of health literacy
Too much reactivity/not
enough proactivity
Confusing system to
navigate
Need more integration
between services
Reliance on system in times
of real or perceived need
Primary drivers:
QIPP LTC Workstream
Risk Profiling
Integrated care teams at locality level
Systematic empowerment of patients to self manage
Integrated teams
• Improved health status, reduced weight and improved diet1,4
• People were most likely to be alive, living independently at
home6
• Improved symptoms and behaviours5
• Improved health status & mental well-being. Outcomes for
lower cost3,7
Source: (1) Kasper “A Randomized Trial of the Efficacy of Multidisciplinary Care in Heart Failure Outpatients at High Risk of Hospital Readmission”. Journal of the American College of
Cardiology Vol. 39, No. 3, 2002
Source: (2) Griffiths. “Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme”. Thorax 2001;56:779–784
Source: (3) van den Hout “Patient team care nurse specialist care, inpatient team care, and day arthritis: a randomised comparison of clinical multidisciplinary care in patients with
rheumatoid”. Ann Rheum Dis 2003 62: 308-315
Source: (4) Capomolla et al. “Cost/utility ratio in chronic heart failure: comparison between heart failure management programme delivered by day-hospital and usual care” J Am Coll
Cardiol 2002; 40: 1259-66
Source: (5) Opie, Doyle & O’Connor “Challenging behaviours in nursing home residents with dementia: a RCT of multidisciplinary interventions” Int J Geriatr Psychiatry 2002; 17(1):613
Source: (6) Stroke Unit Trialists’ collaboration “Organised inpatient care for stroke” Cochrane Library, issue 2, 2004
Source: (7) Ahlmen et al “Team vrs non-team outpatient care in rheumatoid arthritis” Arthritis Rheum 1988; 31(4): 471-9
The Vision in ONEL
Population Size:
227,000
47 GP
Practices
Population Size:
270,000
45 GP
Practices
Population Size:
236,000
 Coordinated care for patients and
carers in the community
Population Size:
180,000
41 GP
Practices
54 GP
Practices
 Optimal patient experience and
clinical outcomes
 Lower cost, better productivity
 Whole system change (1,000,000
patients)
Aims:Integrated Teams
Outline / Aims
of the Project
• Providing Integrated Care services where “the
patient receives the care that they want and nothing
more; the care that they need and nothing less”.
• Partnership working between the GP practice, Social
services and provider services.
• Avoids duplication of services.
Aims: Integrated Teams
• Provides proactive management of long term conditions and
social needs.
• Prevents avoidable hospital admissions because of robust
planned care and patient education
• Reduction in permanent admissions to residential
and nursing homes
Component Parts of ICM
Risk
Stratification
Patient Feedback
Measurement and
monitoring
Co-ordinated care
plans
Networking with
associated
services
Collaborative
team working
Provision of care
to patients
ONEL :Integrated Care Team
End of
Life
Mental
health
GP
Community
Matron
OT
Therapies
Care liaison
officer
Acute
care
specialist
s
Patient
/Carer
Practice
Nurse
(Optional)
Voluntary
Sector
Social Worker
Drug &
Alcohol
services
District Nurse
The Model:Co located
CLUSTER 1
CLUSTER 2
CLUSTER 3
CLUSTER 4
CLUSTER 5
CLUSTER 6
GP PRACTICE x7
GP PRACTICE x7
COMMUNITY
MATRON
COMMUNITY
MATRON
COORDINATOR
COORDINATOR
SOCIAL WORKERS
SOCIAL WORKERS
GP PRACTICE x7
GP PRACTICE x7
GP PRACTICE x5
GP PRACTICE x7
COMMUNITY
MATRON
COMMUNITY
MATRON
COMMUNITY
MATRON
COMMUNITY
MATRON
COORDINATOR
COORDINATOR
COORDINATOR
COORDINATOR
SOCIAL WORKERS
SOCIAL WORKERS
SOCIAL WORKERS
SOCIAL WORKERS
OT
OT
OT
OT
OT
DISTRICT NURSES*
DISTRICT
NURSES*
DISTRICT
NURSES*
DISTRICT NURSES*
DISTRICT NURSES*
DISTRICT NURSES*
LD SUPPORT
(virtual)
LD SUPPORT
(virtual)
LD SUPPORT
(virtual)
MH SUPPORT
(virtual)
MH SUPPORT
(virtual)
LD SUPPORT
(virtual)
MH SUPPORT
(virtual)
LD SUPPORT
(virtual)
MH SUPPORT
(virtual)
LD SUPPORT
(virtual)
MH SUPPORT
(virtual)
MH SUPPORT
(virtual)
*Named District Nursing Sister and allocated Band 5 Community Nurse
OT
Access
Single point of access
Integrated Case Management Overview
The Integrated Care Team
Identify Service User
Community
Planned Care
(health &
social care)
- GP
- Community Matron
- Social Worker
- District Nurse
- Integrated Case Coordinator
- Additional Specialist / Voluntary Sector as needed.
High Risk patients
identified via Health
Analytics and Clinical
Expertise
Care Plan
Review
Self Management
Onward Referral
Ongoing Care
Care Delivery
Care delivery by Integrated
Team as coordinated by
Integrated Care
Coordinator with the
patient
Case Conference & Care
Plan
Fortnightly meetings at practice
level High risk patients
discussed and care plan
Implemented
Rapid response underpins the integrated care model and provides nursing /reablement
unplanned care 24/7 up to 14 days to prevent hospital admissions and promote early
supported discharge
Community
unplanned care
(health & social
care)
Rapid
Response
Provides 24/7 Nursing / Reablement to prevent hospital admissions and support early discharge
Works in partnership with Out of Hours GP services to prevent hospital admission
Admits Patients to step up community beds to provide short term interventional care
Works in partnership with the London Ambulance Services in full to prevent hospital admission
Planning and Implementation
Stakeholder engagement
Planning/ Implementation
 Experience based design videos to
 Outline case presented to each
co-own/produce new ways working
 Workstreams- coproduction
 Visits undertaken to more than 140
GP practices in ONEL
 Stakeholder engagement events
organised for each borough
 Meetings with each stakeholder –
social services, community provider,
acute trust, Public health, Voluntary
 ONEL strategy sessions
 Feedback from patients / pilot sites
at B&D
stakeholder
 Research activity to identify best
practice
 Significant time spent by the QIPP
team in shaping the model of care.
 DH support/Visits to other sites for
learning
 Business cases, Practice
support,Estates
 Governance agreements/documents
 Modelling activity to determine
savings
Integrated Care
programme
Case Study 1
Pre IC:
 No feed back from disciplines
frequent hospital admissions
 no team approach to patient
 poor outcomes
 depression
Post IC:
 More joined up working
 More effective use of services in
the
community
 Patient feels more supported
 Trying to address key issues (pain)
and
more accountable ownership of
particular patient problems via
specialist teams in the community
Overall Outcomes
Quality Outcomes

Over 1300 patients with MDT care plans in place

132 GP practices, 3 local authorities, 2 acute trusts and 1 community provider
delivering the model of care ( Integrated Care Coalition)

Improved co-ordinated care by multi-disciplinary teams and reduced duplication

Every patient has a nominated and dedicated coordinator to coordinate personalised
care

Rapid access to social care as needed through direct referral to social care
Social Care Improvements
•
•
•
•
•
•
•
Reclaiming social work
Shared risk taking
Improved referral pathway
Locality working – personalisation spin offs
Hospital in-reach
Reduction in admissions to residential care
Significant increase in SDS performance
Overall Outcomes
Financial Outcomes

Reduction in length of stay for patients with LTC in comparison to 10/11. 12%
reduction in Waltham Forest and a 9% reduction in Redbridge , 10% in B and D

Reduction in the number of referrals to nursing / residential homes

Increased timeliness of care packages

Reduction in the number of safeguarding referrals
Overall Outcomes
Operational Outcomes

Transformational community nursing workforce development

Co-location of health and social care teams in B&D and Redbridge building “high trust”
partnership teams

Establishment of strong collaborative working with primary/ community teams and
secondary care to support patients across the pathway

Full roll out of integrated data platform to integrated health intelligence from acute,
GP, social care and community data sources across all boroughs to target appropriate
patients for model of care

Improvement in staff retention in services

Now a site for – ‘Year of Care Pilot’ for the DH
Support
• Website, Update, Resources, Virtual programme,
LTC Commissioning Pathway
• Local Support• National Coach (DH) and Queens Nurse- Sharon Lee
Future
The best way to predict the future
is to create it
Peter Drucker