Integrated Care in North West London Innovation in Managing Long-term Conditions

1. Integrated Care in North West LondonInnovation in Managing Long-term Conditions 18 October 2011 Serving the North West London Cluster

2. Integrated care represents a fundamental shift in the way we work From a focus on each individual patient… …to a focus on populations From individual decision-making… …to multi-disciplinary decision-making SOURCE: NWL ICP Operations Team

3. Patient journey Integrated care results in a more structured and streamlined patient journey across care settings Commu-nity care Mentalhealth Primarycare Acutecare Socialcare MDG Case Conferences and ICP informatics tool Primarycare Commu-nity care Socialcare Mentalhealth Acutecare SOURCE: NWL ICP Operations Team

4. Invest to save Shift care from acute to community Population based approach Raise the quality of patient care Align incentives, information & governance Principles of the integrated care pilot 1 • Pilot redeploys resources within the local health economy leading to a productivity gain that improves quality and lowers costs 2 • Funding is withdrawn from the hospital sector and reinvested in out-of-hospital care, closer to people’s homes, and multi-disciplinary in nature 3 • Care is delivered according to best practice clinical pathways agreed by all providers in the pilot 4 • Multi-disciplinary teams of GPs, specialists, mental health, social care, and community care professionals are responsible for the holistic needs of defined populations (elderly and diabetics) 5 • Providers and commissioners all share in the pilot’s success and savings are distributed for reinvestment • IT tool facilitates information sharing and care planning • Joint governance arrangements

5. B The Steering group, with additional clinicians, selected diabetes and the elderly as areas of focus for the pilot based on a number of criteria Selection criteria Patients with diabetes Frail elderly patients Clinical benefits • Diabetes represents a major and growing problem in NWL • High prevalence vs. U.K. average • Relatively less well controlled with large variability • Evidence of programmes that • Reduce length of stay • Prevent falls • Prevent readmissions (lower infection risk) Quality Patient experience • Variable patient experience across primary, community and acute settings • Little proactive care planning • Patient experience can be improved greatly by better integration of health, social care Cost saving potential • Spend per person with diabetes is particularly high in H&F and K&C • Large spend area - spend on patients with known diabetes >5% of inpatient spend • Nationally, frail elderly people occupy • 70% of acute beds and cost over • 45% of the inpatient spend • 55% of social care spend Likelihood of successful pilot • Much clinical enthusiasm • Extensive work in NWL and London already under way which can be leveraged • Successful programs elsewhere • Marked improvements in NWL in LOS in some services and areas • Successful integration of health and social care in other parts of the U.K. (e.g., Torbay) • Impact measurable in terms of acute and nursing home spend The pilot will prioritise these two but have a group for “other opportunities” as well SOURCE: Integrated care pilot team 5 and 13 July 2010 Steering meetings

6. 0 Excludes social care spend B The pilot will focus on diabetes and the elderly, segments that account for 10% of the NWL population but an estimated 28% of the spend £m, PCT adjusted gross spend 2008-9 (100% = £2.2bn) Average spend per person £ Total spend for 380,000 population £m 100% = 2.03m 100% = 2.2bn People with diabetes1 4 2,716 38m 9 6 75 and over 3,863 81m Other people 91% 873 300m Percentage of NWL population, 2008 Percentage of NWL spend, 2008/20092 1 People aged >75 with diabetes are included in the diabetes population segment. Elderly patients who have diabetes are likely to be in the highest need segment, requiring a form of case management for ongoing monitoring and support. These people likely spend time in acute because of their one or more LTCs. When modelling the impact of integrated care we did not want to double-count the effect of elderly initiatives and diabetes initiatives. Therefore we placed people with diabetes who are also elderly (approx 8,669 of the pilot population of 380,000) in the diabetes segment for defining impact on activity and cost. This is because the diabetes and other LTCs that these people have cause them to visit acute often, similar to other high need people with diabetes only. 2 NHS spend excluding social care SOURCE: Integrated care modelling team

7. This integrated and structured approach has the potential to improve patient outcomes and experience, while driving costs down What are we trying to achieve in NWL? Practices serving 506,000 patients are already working with the pilot to start delivering integrated care for their elderly and diabetic patients Over the course of the pilot we aspire to transform care for a population of 750,000 people across five boroughs Acton:~55,000 patients 12 practices Westminster: ~112,000 patients 21 practices Hounslow: ~42,000 Patients 9 practices Hammersmith and Fulham: ~150,000 patients 20 practices Kensington and Chelsea: ~147,000 patients 31 practices Improve patient outcomes and experience through collaboration and coordination care across providers (4 hospitals, 3 community providers, 93 GP practices, 5 social care organisations) with shared clinical practices and information Decrease hospital usage including emergency admissions by 30% and nursing home admissions by 10% for diabetics and frail elderly through better more proactive care Reduce the cost of care for these groups by 24% over 5 years SOURCE: NWL ICP Operations Team

8. Over the last three months, the ICP partners have organised themselves into 9 multi-disciplinary groups (MDGs) that reach over 500K patients • CLH • Practices: 13 • Diabetes: 2,723 • Elderly: 3,420 • Total patients: 63,636 • Acton • Practices: 12 • Diabetes: 1,551 • Elderly: 2,845 • Total patients: 54,917 • K&C North • Practices: 17 • Diabetes: 2,109 • Elderly: 3,407 • Total patients: 74,370 X • Victoria • Practices: 8 • Diabetes: 1,225 • Elderly: 2,618 • Total patients: 47,674 • Chiswick • Practices: 9 • Diabetes: 1,015 • Elderly: 2,218 • Total patients: 41,630 • H&F North Central • Practices: 9 • Diabetes: 2,134 • Elderly: 2,528 • Total patients: 72,486 • H&F Central • Practices: 5 • Diabetes: 1,113 • Elderly: 1,790 • Total patients: 39,908 • H&F South Fulham • Practices: 6 • Diabetes: 688 • Elderly: 1,700 • Total patients: 38,302 • K&C South • Practices: 14 • Diabetes: 1,667 • Elderly: 3,635 • Total patients: 73,492 SOURCE: NWL ICP Operations Team

9. How many GP’s are involved in the ICP? Acton 33 Chicwick 31 CLH 44 H&F C 25 H&F NC 59 H&F SF 32 K&C N 54 K&C S 44 Victoria 23 Total GP’s 345 SOURCE: NWL ICP Operations Team

10. Mental Health Specialist    Acute Specialist Social care Specialist What’s the big idea? Improve the quality of patient care for patients with diabetes and the elderly Local Multi-Disciplinary Groups… …working in a Multi-Disciplinary System Group 1 5 Sub-Group Patient registry Care delivery Practice 2 6 Risk stratification Case conference GP District nurse Community matron 3 7 Clinical protocols & care packages Performance review 4 Practice nurse Social care worker Community Mental Health Care plans Patient, user and carer engagement and involvement Joint Governance through IMB with a shared performance and evaluation framework Aligned Incentives through an innovative financial model Information sharing to access and analyse data in a timely fashion Organisation and culture development

11. What does a Multi-Disciplinary Group do? 1 2 7 Each MDG holds a register of all patients who are over the age of 75 and/or who have diabetes The MDG uses the ICP information tool to stratify these patients by risk of emergency admission The MDG meets regularly to review its performance and decide how it can improve its ways of working to meet the Pilot goals 7 Performance review    4 1 2 Care planning Patient registry Risk stratification 5 Care delivery1 GP Practice nurse 6 Case conference 3 Districtnurse Social care worker Shared clinical protocols Community pharmacist Community Mental Health 3 4 5 6 All providers in the MDG agree to provide high quality care as laid out in the Pilot’s recommended pathways and protocols Patients receive care from a range of providers across settings, with primary care playing the crucial co-ordinating role and every body using the ICP IT tool to coordinate delivery of care A small number of the most complex patients will be discussed at a multi-disciplinary case conference, to help plan and coordinate care Each patient is then given an individual integrated care plan that varies according to risk and need 1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review

12. Example Clinical Pathway: Newly Diagnosed Type 1 Diabetes Diabetes induction • Patient receives initial introduction to diabetes, including explanation, education and scheduling of future appointments. This must be completed within a month of diagnosis. • DSN + dietician • 60 mins • Once Diabetic tests • Standard set of diabetes tests (including BMI, BP, blood tests, foot check and urine check). This must be completed within a month of diagnosis. • Part of First Consultation • … • Once Activity What is it? Professional Duration Frequency First consultation • Diagnosis is explained to the patient • Written information on diabetes and joining local and national organisations is provided • Consultant + DSN • 45 mins • Once Care planning • Meeting to plan patient's care over the next 12 months that should cover both diabetes and non-diabetes related health issues. During the meeting, the patient should be asked for consent to being part of the ICP. The patient should leave with a written care plan. This must be completed within a month of diagnosis. • Consultant • 30 mins • Annual Retinal screening • Retinal screening by an accredited provider • Refer screening program • 40 mins • Annual Structured education • Refer with explanation of purpose to DAFNE/ICICLE patient programme • Secondary or community care centre • 5 mins • Once Quarterly review • Review of care for all patients during first year after diagnosis. At minimum, BP and HBA1C should be measured. Other tests are at clinical discretion. • Consultant • 20 mins • Every three months 11

13. £79,622 Highest risk – 350 patients • Care planning appointment • 10 follow-up appointments annually • 5 discussions in GP meeting annually 5% 50% £138,501 High risk – 1,181 patients • Care planning appointment • 5 follow-up appointments annually • 2 discussions in GP meeting annually 17% 50% £146,135 Medium risk – 1,906 patients • Care planning appointment • 3 follow-up appointments annually • 1 discussions in GP meeting annually 27% 50% EXAMPLE RESOURCE PLAN MDGs use to create an ICP resource plan % of planned care that is incremental1 Patient segment Package of planned care Incremental cost £0 Lower risk – 3,522 patients • No care planning appointment • No follow-up appointments annually • No discussions in GP meeting annually 51% Total: 0% £364,259 1 I.e. the proportion of this activity that is completely new, as opposed to a codification of existing activity

14. Benefits extend beyond reduced emergency admissions… • Improved awareness of available local services e.g. Falls service • Increased awareness of the scope of other professionals’ rolesand abilities, e.g. role of community matrons • Shared learning about a variety of conditions, drugs and services e.g. the impact of needle length on insulin effect • Highlighted areas that may need further attention, in individual patients and the overall population, e.g. the need for formal cognitive assessments in many of the elderly • Valuable discussions involving all disciplines, taking a holistic view e.g. complicated diabetics with psychiatric co-morbidity & heavy drug burden • Professional support, e.g. reassurance that there is no more that can be done, or alternatively, suggestions for investigations and management in complicated case • Increased Coordination and collaboration with Social care, only forum where Health and social care specialists meet regularly to discuss coordinated health and well-being actions • Reduction in inappropriate Outpatient referrals, through improved communication and focused care planning, inappropriate referrals should be reduced SOURCE: NWL ICP Informatics group

15. Benefits extend beyond reduced emergency admissions… • Tangible changes in the way clinicians are working together • A&E pre-DTA telephone call to GP: e.g. 1 MDG has set up an 0800-2000hrs GP rota with a dedicated Mobile which admitting consultant will call prior to final decision to admit • Imperial Diabetic Nurse Specialists working in Primary care & up skilling practice nurses • Potential use of tool as primary referral method: • GP-consultant email service with a 24-hour turnaround • Experimentation with different case conference forums (e.g., telephone conferences), preparation templates, etc.. SOURCE: NWL ICP Informatics group

16. Early feedback from clinicians has been positive (1/2) N=72 Today’s case conference was a good learning experience for me Neither agree nor disagree 4 64 32 Agree Strongly agree I feel satisfied with my personal contribution today 4 64 32 I believe the advice I received or gave today will help prevent an emergency admission 4 65 31 More than 90% of responses were Positive across the board This multi-disciplinary way of working has huge benefits for more joined up management and better relationships between all professionals. This will be very valuable for gathering ideas, and highlighting where there are issues/ glitches in the system, and will act as a foundation for more fundamental and system-wide change ~ General Practitioner Our multi-disciplinary discussion was a hugely valuable professional learning opportunity for me – I have already seen the benefits in the way I am treating my own patients, and am excited to see how this way of working will benefit the system overall ~ Community Matron SOURCE: NWL ICP Operations Team; Feedback from case conferences (clinicians & external observers)

17. Early feedback from clinicians has been positive (2/2) Common feedback Quotes Case confer-ences • Multi-disciplinary input seen as benefitial for patients in most cases • Good opportunity for joint learning across disciplines, enabling more enjoyable and rewarding ways of working together • Multi-disciplinary way of working will act as a foundation for system-wide change by allowing clinicians to identify and problem solve around glitches in the system “Excellent joint learning opportunity – I really enjoyed interacting with the other members of the MDGs and gaining a better understanding of their roles” “Our discussion highlighted areas that need further attention, like formal cognitive assessments for the elderly” “Loved the opportunity to problem solve together on where we can strengthen the system” Care planning • Collaboration in care planning seen to be benefitial for patients and professionals alike • Standardized clinical protocols believed to have the potential to significantly improve quality of care • IT tool seen as useful in sharing patient data and tracking activity across settings • Advice on referral pathways and available services valuable in streamlining care “So useful to have access to a consultant for advice on the best care plan for my patients. Also great to be able to discuss general local service issue with other GPs “Really good advice about where and who to refer to in future – this will enable us to streamline care and reduce the number of patients getting ‘lost’ in the system” “IT tool enormously improved! I have managed very quickly to find pt, do consent and create care plan” SOURCE: NWL ICP Operations Team; Feedback from case conferences (clinicians & external observers)

18. An example of a successful case conference discussion Case summary • 84-year-old woman • Severe pain due to multiple lumbar spine compression fractures • On buprenorphine patches, which DN is supposed to apply once a week (as well as PRN co-codamol and oramorph.) • GP has referred 4 times with no response and is currently applying patches • Unpredictable pain results in frequent 999 calls and A&E attendances • A&E unable to do much and sends her back home • GP has referred to social services, referred to physio, and discussed with the acute pain team Impact of discussion • GP to consider other therapeutic agents (lignocaine patch, neuropatchic agents) • GP to inform LAS of situation so that they can contact GP/OOH service before transferring patient • GP to consider psychological input re coping strategies • Community matron attendee to follow-up with DN service SOURCE: NWL ICP Operations Team; Feedback from case conferences (clinicians & external observers)

19. Four information issues prevent delivery of widespread integrated care Care plan Patient A Care plan Patient A 2 1 No single patient care episode plan Difficult to identify high risk patients • Difficult to identify high risk patients easily using current systems • This makes planning proactive care difficult • No single view of all the care that a patient is receiving in different settings • This inhibits care monitoring and coordination 3 4 No single view of patient medical information Difficult to compare GPs practices ? GP Patient Information Hospital Patient Information Community Patient Information • Multiple patient records stored in different care settings • This makes decision making sub optimal • Difficult for GPs to know how they are performing relative to their peers • This makes spreading best practice difficult 18

20. The ICP IT supports 4 key processes Care plan Action 1 Action 2 Action 3 2 1 Integrated Patient Care Planning Patient Risk Stratification Action: Review by falls service Action status: Completed • Identify high risk patients using population segmentation and risk stratification • This enables proactive care to be planned • Plan care for patients, share these plans across settings, and monitor progress • This helps better coordinate care 3 4 Patient Medical Information Sharing Performance Evaluation Patient records: GP Hospital Community • View patient medical information from multiple settings • This enable integrated care to be provided • Track and evaluate the performance of GP’s surgeries and Multi-Disciplinary Groups • This helps spread best practice in patient care 19

21. The tool will help identify high risk patients…

22. The tool will enable Integrated Care Plans to be created for the first time

23. Ensuring that there are appropriate ‘hand-offs’ between organisations

24. For the first time, professionals will be able to see relevant information from across settings of care in a single, secure place

25. The tool will facilitate robust performance management and evaluation of the pilot to ensure it delivers results

26. The ICP Web Portal can be used to identify high risk patients The risk stratification screen allows health care professionals to identify high risk patients A number of different metrics can be used to help in this task They can then click on any of the bars in the graph to see which patients fall into that risk category

27. Integrated Care Plans help coordinate the care for patients within the Pilot The Portal can be used to create and manage Integrated Care Plans for patients Text Standard care packages can be selected by clicking on any of the template buttons, the actions in this care plan will then be selected Individual actions can then be added or removed from the care plan

28. The portal can also be used to share patient information across settings This screen shows some basic information about the patient It also shows the patients prescription history The prescription history can be filtered and sorted to better be able to find information

29. Actively participate at case conferences Support and take part in care planning Change how care is delivered What are the responsibilities of a service provider in the ICP? • Identify and prepare patient cases for discussion (e.g., inpatients, social service users with health issues, etc.) • Support MDGs in creating initial care plans for all diabetic patients and 50% of patients aged 75 and over(e.g., by providing seconded nurses to the MDG) • Give specialist input on patient cases brought by other participants • Modify care plans with patients’ GPs as needed • Be the expert for the MDG on the full range of available services and resources • Follow-up on questions and actions generated through the case conference • Use the ICP IT tool to see range of patient data and history across multiple settings • Discuss MDG performance, identify opportunities for improvement, and allocate out-of-hospital investment • Complete “actions” (referrals) and regularly monitor activity • Identify system gaps and opportunities • Collaborate with MDG partners on day-to-day basis (e.g., direct phone call to GP upon A&E attendance) • Identify best practice across MDGs Review performance & identify improvement

30. Each MDG must go through an intensive multi-step ‘mobilisation stage’ Formation and governance Data extraction Care planning design & set-up Care planning roll-out Authorise data extraction Sign-off templates Plan rate of activity Sign-up Approve resource plan Complete data extraction Map services Organise support Clarify governance Customise IT tool Set-up & train users [MDG] Set-up & train users [GPs] Establish baseline Risk-stratify patients Invite patients Start care planning SOURCE: NWL ICP Operations Team

31. Leadership Joint governance Clinical pathways and MDG mechanics Financial MDG formation, application and development Information Organisational development What is required to build a successful Integrated Care virtual organisation • Establish Integrated Management Board with executive level leadership (CE/MD level) for participating organisations including terms of reference, voting rights • Establish committee structure (e.g., pathways, info, finance, etc, co-chairs and members) • Select pathway, informed by clinical evidence, best practice and local needs • Establish clinical working group with leading clinicians (ie heads of relevant department in hospital, leading GPs and community health leaders) • Agree risk stratification and care package including resourcing envelope • Agree key metrics for monitoring • Define mechanics for multi-disciplinary working (i.e., balance time needed from specialists) • Establish leadership coalition– Pathfinder leads, PCT Cluster, Hospital CE(s), Community Health Service CE/MD, Local Authority CE/DASS • Crucial to ensure buy in to vision and appetite to make #1 agenda item • Profile health economy with patient level data on activity and cost • Model savings from interventions and cost of care coordination and care packages • Establish scale up impact based on population in pilot, pathways in pilot and timeline • Agree incentive mechanism and implication for all providers • Agree how upfront investment is used to fund additional activity and operational team • Identify local clinical leaders, supporting them to build clinical coalition leading to MDGs • Agree on resource plan principles, content and peer-review process • Define local MDG operating and financial model, and complete resource plan submissions • Begin holding MDG meetings – and for into a true team • Build technical requirements for sharing data, care planning, risk strat and performance • Evaluate existing IT solutions, and determine scope for required bespoke IT development • Design a usable ‘front-end’ clinical portal with regular interaction with clinicians • Build ‘back-end’ datawarehouse by integrating all required data sets • Review IG requirements and build into security rules • Complete legal data sharing agreements • Establish organisation team • Train frontline users on use of information tool • Continue to reinforce ‘new ways of working’ via team events