NHS Stoke on Trent

1. NHS Stoke on Trent • 270,000 registered patients, 54 GP practices • 2 new GP practices and GP led Health Centre planned for 2009 • Some of the most deprived wards in England, • 5 PBC clusters closely aligned with the Local Authority neighbourhood areas WM AHSN clinical priority: Long Term Conditions Professor Ruth Chambers OBE, GP & Clinical telehealth lead, Stoke-on-Trent CCG Honorary professor Keele & Staffordshire Universities

2. AHSN Long Term Conditions Priority Integrated Care Adoption & Diffusion Education & Training Wealth Creation Digital Delivery Clinical trials Mental health Drug safety LTCs

3. It’s about the basicsimproving delivery ofbest practice care for long term conditionsvia patient empowerment, integration & innovation

4. Most people with any long term condition have multiple conditions (eg Scotland)

5. Multimorbidity is common in UK • The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions • More people have 2 or more conditions than only have 1

6. People with multimorbidity are much more likely to have emergency and potentially preventable admissions

7. International evidence shows that people with multimorbidity experience more problems with the coordination of their care

8. Right treatment for LTC, right delivery, right time, right team, right intensity Secondary care (tier 3, tier 4) Community care & social care Primary care (esp general practice, pharmacy) Personal responsibility & self care

9. Digital delivery can support the whole patient pathway Supporting People at Home Manage step down from acute effectively Enhanced support at home Home Home Support* Crisis Acute Trf of care Support Long term hypertension Smoking Cessation Long term vital signs monitoring Care Homes Pain Mment Medicines Management “Worried Well” INR Weight loss motivational messages Health self assessment Sexual health Long term hypertension Smoking Cessation Long term vital signs monitoring Care Homes Pain Mment Medicines Management “Worried Well” INR Weight loss motivational messages Health self assessment Sexual health Unstable Hypertension Newly diagnosed hypertension Medication Reminders for: - Hypertension / Ashma inhaler / pain management Paediatric ashma COPD Diabetes (type1& 2) Heart Failure Palliative care carer support/wellbeing Falls prevention EMAS unstable vital signs monitoring Oncology Neurology Speech therapy Alcohol support Learning disabilities Mental health behaviour Mental Health appt & medication reminders/ supportive messages Daily living/ medication reminders for people with Aspergers/autism Pregnancy induced hypertension Gestational diabetes COPD CHD Diabetes physiotherapy Monitoring of pre op patients to reduce cancelled operations Out patient acute specialist follow up DNA management Support early discharge Virtual Wards Intermediate care Step down facilities Unstable vital signs monitoring Medication management As * Manage Crisis Effectively Supporting people at home Enhanced support at home Specialist acute input

10. Palliative Care HF Nurse Tier 3 Service MDT Inpatient Care Cardiac Rehab Consultant Assessment Accredited GP/ PN HF Nurse Support Education/Training/Support Community Matron Primary Care Core GP Service Out patient Cardiology Rapid Access CP Clinic ECHO Practice Nurse District Nurse GP Home SC Diuretics Patient Self Care Weight Management Fluid Restriction Symptom Monitoring Lifestyle Changes Urine Analysis Full Blood History Examination Manage Co-morbidities ECG BNP CXR A/E Education Drug Therapy Manage Co-morbidities Organise Follow-up Individual Management Plans None Pharmacological Interventions Individual Management Plans Worsening Symptoms Despite Treatment

11. WMAHSN LTC stakeholder consultation –so far LTCs Adoption & diffusion Education Digital delivery Wealth creation Patient upskilling eg avatar, apps Databases: successful LTC innovations, patient stories, shared management plans Web resource Flo telehealth- exemplars Beacon sites; rollout GP/social care integration Clinical champions; patient champions Virtual patient information leaflets /app Computerised decision support Asthma COPD Hypertension Heart failure OA AF Diabetes & obesity Empowering patients Shared management Upskilling patients Integration Themes Program Interventions

12. Helping patients to help themselves £ free to txt all my teams Readings & answers patients mobile phone Closed loop Opt-in/out, prompts, questions, feedback, advice, education clinician smartphone Alerts if needed web

13. Working with industryDesigned for collaboration Enabling an industry & academia eco-structure, building on the core

14. Working with CCGs: eg risk profiling –underpinning evaluated innovations Low cost, large-scale: ‘simple telehealth’

15. Focus on patient perspectives of clinical conditions? Enriching self care as agreed shared management Helping people to help themselves – as agreed with their clinicians – throughout all tiers of care

18. Looking forward ?