Transcript Clinical Working Groups Integrated Care Pilot – Elderly Care

Outer North West London CCGs
Integrated Care Pilot (ICP):
Business Plan 2013/14
Dr. Mohini Parmar
Ealing Health and Wellbeing Board & Ealing CCG
26th March 2013
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What is the Outer North West London Integrated Care Pilot?
1 Patient registry
All patients with a condition
(diabetes and 75+) are
identified...
5 Care delivery
… which are
communicated to all
professionals
automatically…
2 Risk stratification
….and automatically risk
stratified, allowing
clinicians to see who the
most in need are….
6 Case conference
3 Care pathways
…Agreed care pathways
mean care is
standardised…
7 Performance review



4 Work planning
… Patients and
professionals work
together to agree their care
needs …
…When people with very
complex needs are
identified then case
conferences with a range
of health and social care
experts are used to plan
their care…
The pilot participants use
performance metrics to
review the success of their
interventions …
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How is this Vision Being Delivered?
This is being delivered by forming Local MultiDisciplinary Groups…
Group
Primary Health Care Team
Each MDG has a number of monthly
case conferences to case manage
complex patients
Practice
Social care
Specialist
GP
District
nurse
Practice
Nurse
Community
matron
Social
Community
Care
Mental Health
Representative Representative
Mental
Health
Specialist
MDGs Monitor performance and agree
which pathways are being undertaken
by the group
Acute
Specialist
…and supported by a set of key enablers
Patient, user and carer engagement and involvement
Joint Governance through IMB and Borough based IMG with shared performance framework
Aligned Incentives through an innovative financial model
Information sharing to timely access and analyse data
Organisational development and culture
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Some Quotes About the ICP
‘There isn’t a single member of my staff who hasn’t built relationships, built knowledge, shared
knowledge and promoted services. They like the fact they’re appreciated. GPs will speak to them and
‘pick their brains’. They were sometimes intimidated or irritated by GPs in the past and they have broken
down barriers and see them as more human.’
Social Care, Ealing
‘Doing the care planning opens your eyes to many things you do not normally check. It is really
interesting.’
GP, Ealing
‘The mobilisation has been incredible and the organisation excellent. My experience of multiagency
projects is that they slip – this didn’t. It hit the target bang on. MDGs were due to start in August and they
did’
Social services, Ealing
‘Listening to all the people who participate in the ICP, there is encouraging enthusiasm and optimism that
for the first time we have a means of working together to provide truly multidisciplinary patient focussed
care for those with long term conditions.
Acute Care Consultant
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Achievements in 2012/13: Key Milestones
•
As of March 2013, the ICP now covers a population base of 1.2m in ONWL
•
Diabetic and elderly care pathways rolled out at inception of Pilot
•
COPD and cardiac pathways are now developed and ready for roll-out in early
2013/14
•
88% of GP practices by population in Ealing are now taking part in the ICP.
•
100% of patient discussed what was most important to them in 100% of patient
discussed what was most important to them in managing their own health
•
68% of patients believe they received a good amount of information during
these sessions
•
96% of patient think that having the care planning discussion has helped
improve how they manage their health problem.
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Business Plan 2013/14 - Direction of Travel
•
The patient is at the centre of their care planning, thus evolving the case conference
model to improve efficiency and utilisation of clinician time, and timely feedback to
patients;
•
Focussing on the quality of care planning, ensuring each patient gets the same
standard of care;
•
Breaking down organisational boundaries in terms of information sharing with patient
consent;
•
Moving to a model which plans care for all patients above a pre-determined risk
stratification score rather than specific pathways that is truly integrated care across
social and health care providers
•
Responding to the “Whole Systems Integrated Care” agenda and moving towards a
system of ‘shadow budgets’ as part of which providers have the opportunity to share
cost and revenue information;
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Why Should Ealing Support Integrated Care?
•
Improve patient experience and reduce admissions when they can be cared for in the
community. We have to try to control unscheduled admissions and A&E attendances –
ICP is an effective way of doing this.
•
The evidence that ICP is changing clinical practice is strong, through multiprofessional (MDG) meetings and shared learning.
•
There is a strong push from the NHS and from bodies representing patients to connect
up different parts of the NHS and social care so that functions and roles are not
duplicated, we fully acknowledge this and support the opportunity for more joined up
working.
•
Ealing CCG Board has already indicated its support for the Business Plan.
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Next Steps 2013/14
•
The Business Plan has been approved by Ealing CCG.
•
We will be looking for pump-prime funding from the NHS Commissioning Board to
continue the Pilot in 2013/14.
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