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ProMISE The Bromley Programme

ProMISE The Bromley Programme. Sam Merridale, Programme Lead June 2012. The Local Context. Large ageing population >16% in 2011 Diabetes, cardiac and respiratory commonest cause of ill health Carers and dementia probably under recognised Current service delivery often fragmented & reactive.

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ProMISE The Bromley Programme

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  1. ProMISEThe Bromley Programme Sam Merridale, Programme Lead June 2012

  2. The Local Context • Large ageing population >16% in 2011 • Diabetes, cardiac and respiratory commonest cause of ill health • Carers and dementia probably under recognised • Current service delivery often fragmented & reactive

  3. The Vision Improve the health of our older population with complicated health & social needs in Bromley

  4. The Goals • Inform patients and promote independence • Identify most vulnerable & over 65 • Design care plan around the patient’s needs • Manage their care through coordinating services effectively

  5. The Objectives • Develop a tool to identify most vulnerable • Create a cohort of people “virtual ward” • Design patient-centred care-plan • Deliver quality service-coordinated, targeted and appropriate • Promote self-care and education for patient & carers • Improve communication between care-givers

  6. Outcomes • Improve clinical outcomes, reducing unplanned admissions and length of stay in hospital • Improve patient’s experience, broadening their understanding of their health needs and self-care measures

  7. Developing a Culture Shift • Key driver is to improve care for our older population • Need for better respect, improved understanding, shared commitment, opportunities for learning & support-> effective collaborative working

  8. The next step-Phase One • 2 community matrons & 2-3 GP Practices • Testing out the pathway with existing services • Results & progress will inform and enable us to improve and refine services based on active cases • Start education programme in primary care

  9. Programme Implementation • Managed process • Programme management team – meet weekly • Agree programme structure, priorities and case for change • Engagement – critical to success

  10. Programme Governance • Programme Board – responsible for all decisions and moving the programme forward • Clinical Advisory Group • Stakeholder Reference Group • Programme Implementation Group

  11. Accountability • Health and Wellbeing Board – Financial oversight of shared budget • Bromley Clinical Commissioning Executive • Bromley, Bexley, Greenwich Programme – Clinical Strategy Group

  12. Primary care clinicians London Borough of Bromley Bromley Healthcare South London Hospitals NHS Trust Oxleas Trust London Ambulance Service Bromley Links Bexley CCG Greenwich CCG NHS SL Cluster St Christopher’s Voluntary Sector EMDOC … etc Stakeholder Engagement

  13. Interesting issues!! • Case finding – using risk stratification, but also clinical knowledge • Data sharing – across organisational boundaries, and critical to success • Metrics for evaluation – must be consistent with others • Telehealth – explore the principles of how this will support true integrated care – it’s not just about expensive gadgets

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