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Local Commissioned Service for Frail and Elderly Complex Care Case Management

This service supports improved identification, coordination, and integrated care for frail patients with complex needs, resulting in reduced use of unscheduled health and social care. General practice plays a key role in the program through patient identification and assessment, case management, MDT meetings, and training and education. The LCS process map has undergone revisions, and future developments include federated GP practices and the possibility of an FE Integrated Practice Unit.

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Local Commissioned Service for Frail and Elderly Complex Care Case Management

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  1. Frail and Elderly Complex Care Case Management Locally Commissioned Service (LCS)Dr Lance SakerCCG Governing Body member and Clinical Lead

  2. Role of the LCS within the FE Programme • Supports improved identification of frail patients with complex needs. • Improves the co-ordination of care for those patients. • Supports delivery of an integrated model of care. • Supports a reduction in use of unscheduled health and social care • Is the underpinning of the whole FE programme.

  3. Role of General Practice in the FE Programme Working with the people of Camden to achieve the best health for all • 1. Identification and Assessment • Regularly review patients on lists. • Enter suitably frail patients onto the frailty register. • Record a full frailty assessment • Record a comprehensive care plan. • Use the designated Camden EMIS templates. • 2. Case management of patients on register • Decide on level of need – in practice or hub? • In practice – MDT case management in place. • Hub – refer on and ensure delivery of actions arising.

  4. Role of General Practice in the FE Programme Working with the people of Camden to achieve the best health for all • 3. Practice Based MDT Meetings • Must include patient’s case manager, GP and community team rep. • Meet at least quarterly. • Patients can be stepped down from case management if risk of unscheduled need reduces. • 4. Training and education • All clinicians at the practice to undertake a learning module. • One member for peer education at MDT Hub every 6 months. • Practices to undertake adult safeguarding training.

  5. The CCCM LCS Process Map

  6. Revisions to original LES Working with the people of Camden to achieve the best health for all • A Complex Care Management LES was in place 13/14. • Was accompanied by a Risk Stratification ES. • New LCS incentives practices to do a detailed assessment of need, to further increase referrals to the MDT Hub. • Removed the requirement to undertake audits. • Payment for case management is being replaced by proactive home visiting and in-practice consultation.

  7. Payment Schedule Working with the people of Camden to achieve the best health for all

  8. Impact of the LCS

  9. Variation by practice

  10. Variation in care plans

  11. Further impact

  12. Potential Frailty Gap

  13. Future Developments Working with the people of Camden to achieve the best health for all • Federated GP Practices • Proposed development of an FE Integrated Practice Unit • Taking forward the ‘Vanguard’ possibilities

  14. The Future circa 2017/18? Diagnostics GP Front End (Hub) 8am-8pm- commission • Key in year changes • Integration with acute • Commission GP front end front end hub GP Federation Admin Hub Link to GP OOH/111 Specialist services Core GP service Elective GP (Spoke) 8am-8pm Unscheduled Care 8am-10pm Chronic Disease Management MDT working Outreach to home Camden Community Service (CCS) • Minor injury • Diagnostics • Ambulatory Care • Link to GP OOH/111 • Community LTC Hub • Specialist clinicians • Advice and Guidance • Cross-cutting • services Chronic Disease Management Community Services • Community and Social Care teams • Rehabilitation • Link to community beds • Rapid Response teams • Outreach to local population Non-elective A&E • In-reach to hospital Secondary care Underpinned by: Continuous focus on prevention Workforce development via partnership work across providers Shared / interoperable records system (CIDR)

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