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Statistics

Statistics. Long term conditions represent…. 170,000 people die prematurely of long-term conditions each year. The average annual health cost…. Significant variation across PCTs exists in emergency hospital use. The Case for Change. 252%. rise in over 65 year olds by 2050. 188%.

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Statistics

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  1. Statistics Long term conditions represent… 170,000 people die prematurely of long-term conditions each year The average annual health cost… Significant variation across PCTs exists in emergency hospital use

  2. 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

  3. The Case for Change Current Spend 2011 Pay: 3+ Long Term ConditionsDate: 2011 Amount in Words: Nineteen Billion Pounds Signed: __________ £19,000,000,000 Projected Spend 2016 No health care system is sustainable in the face of this tsunami of need Pay: 3+ Long Term ConditionsDate: 2016 Amount in Words: Twenty Six Billion Pounds Signed: ___________ £26,000,000,000

  4. The systems perspective The patient perspective

  5. Primary drivers: QIPP LTC Workstream Risk Profiling Integrated care teams at locality level Systematic empowerment of patients to self manage

  6. 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 CollCardiol 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):6-13 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

  7. The Vision in ONEL Population Size: 270,000 Population Size: 227,000 45 GP Practices 47 GP Practices Population Size: 236,000 • Coordinated care for patients and carers in the community • Optimal patient experience and clinical outcomes • Lower cost, better productivity • Whole system change (1,000,000 patients) Population Size: 180,000 54 GP Practices 41 GP Practices

  8. 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.

  9. 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

  10. Component Parts of ICM

  11. ONEL :Integrated Care Team Therapies Acute care specialists End of Life Mental health Voluntary Sector Drug & Alcohol services

  12. The Model:Co located CLUSTER 1 CLUSTER 4 CLUSTER 5 CLUSTER 6 CLUSTER 2 CLUSTER 3 GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x5 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) GP PRACTICE x7 COMMUNITY MATRON COORDINATOR SOCIAL WORKERS OT DISTRICT NURSES* LD SUPPORT (virtual) MH SUPPORT (virtual) *Named District Nursing Sister and allocated Band 5 Community Nurse

  13. Access Single point of access Integrated Case Management Overview The Integrated Care Team Identify Service User • GP • Community Matron • Social Worker • District Nurse • Integrated Case Coordinator • Additional Specialist / Voluntary Sector as needed. Community Planned Care (health & social care) High Risk patients identified via Health Analytics and Clinical Expertise Care Delivery Care Plan Review Case Conference & Care Plan • Care delivery by Integrated Team as coordinated by Integrated Care • Coordinator with the • patient Self Management Fortnightly meetings at practice level High risk patients discussed and care plan Implemented Onward Referral Ongoing Care 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

  14. Integrated Care programme Planning and Implementation Stakeholder engagement Planning/ Implementation • Experience based design videos to 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 • Outline case presented to each 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

  15. Patient BM 80 year old F in top 1% who needed more intervention as time progressed MHX: AF, CCF, Hypertension, PVD, COPD under 4 specialist teams (London and local) Social: Lives alone, help from niece, carers going in twice a day 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Support • Website, Update, Resources, Virtual programme, LTC Commissioning Pathway • Local Support- • National Coach (DH) and Queens Nurse- Sharon Lee

  21. Future The best way to predict the future is to create it Peter Drucker

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