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DESCRIPTION
The Atos Origin Alliance will provide an overview of how eHealth can support the delivery of high value, coordinated and personalised care for people living with Long Term Conditions. There will be particular focus on how we can support the Reshaping of Older People’s Care pathway from a whole systems perspective.
Citation preview
E HEALTH – ENABLING HIGH QUALITY AND CO-ORDINATED CARE FOR PEOPLE LIVING WITH LTC’s
CONTENT
1. Some key challenges
2. Integrating Care – supporting MDT’s
3. Reshaping delivery of Older People’s Care
4. E Pharmacy current and future opportunity
5. The benefits
HEALTHCARE DEMAND IS GROWING
Demographic change for population aged 65+ ScotlandPotential impact on emergency bed numbers 2007-2031
0
2000
4000
6000
8000
10000
12000
14000
16000
Y/E Mar 2007 Projected2011
Projected2016
Projected2021
Projected2026
Projected2031
Year
Be
ds
A new NinewellsHospital by 2031!
Macro IntegratorNHS Tayside and Angus Council
724
10148
25372
72487LTC’sAsthma
6101COPD2056
Diabetes4698
HBP16423
CHD5318
LEVEL 1HEALTHY
COMMUNITIES
2%LTC
Population
LEVEL 2SUPPORTED SELF CARE
VIRTUALWARD
ANTICIPATORYCARE PLANS
PATIENT PASSPORTS
CASEMANAGEMENT
LEVEL 4INTENSE
CASE MANAGEMENT
LEVEL 3CASE
MANAGEMENT
PRO-ACTIVECONTACT
SUPPORTINGSELF CARE
70%LTC
Population
28%LTC
Population
66%Overall
Population
Obesity11854
PRO-ACTIVECONTACT
SUPPORTINGSELF CARE
North West
187
North West
2631
North West
6577
North West
18790
North East
191
North East
2673
North East
6684
North East
19096
South
346
South
4844
South
12111
South
34601
ANGUS CHP – PATIENT PROFILE
Virtual Wards focusing on Tier 4 , Innovative Step Down Services are key to success!
Project DefinitionStatement
Benefits Statement
Project Status Report
ENSURE OUTCOMES ARE DELIVERED….
Is used for:
1. Stating your case for change
2. Current state analysis
3. Evidence / Data4. Envisaged Change5. Summarise
benefits
Is used for:
1. Define benefits in detail
2. Define appropriate measures
3. Summarise enabling changes ( PP&T)
4. Summarise milestone tracking
Is used for:
1. Report on delivery progress.
2. Report on Benefits Realisation against plan.
3. Escalate to Project Board or EMT for decision, support etc
Multi- disciplinary Project Board, Clinical and Finance essential
RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 1
Programme No Outcome 1
Outcome 2
Outcome 3
Outcome 4
Outcome 5
Outcome 6
Outcome 7
Outcome 8
Outcome 9
Outcome 10
Maintain people at home
Avoid Social Admission
Reduction in hospital admission
Avoid re-admission
Avoid DelayedDischarge
Reduced Bed Days
Reduction in Acute Beds
Reduction in Care Home placement
Reduction in Care Home admissions
Reduction in acute psychiatric beds
W1 Housing with care P1
W1 Effective assessment in community
P2
W1 Continuing Care in Care Home
P3
W1 Telehealthcare P4
W1 At risk assessment and support
P5
W1 Integration P6
W2 Improve service for people living with Dementia
P7
W2 Enhance OT & Equipment Service
P8
W2 Carer Support P9
W2 Capacity Building & Co-production
P10
W2 Improved models of public information
P11
Programme No Outcome 11
Outcome 12
Outcome 13
Outcome 14
Outcome 15
Outcome 16
Outcome 17
Outcome 18
Outcome 19
Outcome 20
Reduction in emergency respite placements
Improved quality of life for patient and carers
Improve service user and carers health
Improved Efficiency
Sustainable joint workforce with right skills mix
Reduction in building costs
Integrated assessment framework
Build community resilience
Develop social enterprise
Increased choice
W1 Housing with care P1
W1 Effective assessment in community
P2
W1 Continuing Care in Care Home
P3
W1 Telehealthcare P4
W1 At risk assessment and support
P5
W1 Integration P6
W2 Improve service for people living with Dementia
P7
W2 Enhance OT & Equipment Service
P8
W2 Carer Support P9
W2 Capacity Building & Co-production
P10
W2 Improved models of public information
P11
RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 2
TECHNOLOGY ENABLING INTEGRATED CARE
Integration Platform
Acc
ess
De
vice
Use
r
Se
curit
y
Ap
plic
atio
ns
Clinical Portal
PMS GPCommunity
Health&Social
Virt
ual
Dat
abas
e
Se
rvic
e
Sta
ff ID
RB
AC
TELEHEALTH
Complex Case
Management
CaseManagement
Pro-activeContact
Prevention
Collaboration Tools
Clinician Manager Administrator Patient
TELECARE
PREDICTIVE RISK
BUSINESS ANALYTICS
IHI CARE CO-ORDINATION MODEL
Goals(G) Co-ordination(C)
ValueProposition
Family, associated assets
PATIENTIDENTIFICATION
OUTCOMES
For people with multiple
needsFamily Social CarePeer GroupsCarer/s Voluntary
Supporting with
enabling technology
Predictive RiskTools
GP SystemsCommunity Information
Systems
TelehealthTelecare
Performance Management
Business Analytics
Personalised Multi-channel interfacePerson Centred
CARE CO-ORDINATOR
ServiceDelivery
ServiceDesign
INTEGRATED CARE(VIRTUAL WARDS) - THE CHALLENGE
• Emergency admissions and associated bed days not hitting HEAT T12 target..
• Challenge around Health Population Management (HPM)
• Lack of effective collaboration between Health and Social Care
• Alignment of e Health with key HEAT T6-T12 outcomes
• Key improvement areas:
1. Reduce all age Emergency Beds
2. More effective HPM
3. Standard operating procedures
4. Effective MDT working
5. Effective medication concurrence
ePharmacy Programme
SUPPORTING THE NEW COMMUNITY PHARMACY CONTRACTAcute Medication Service eAMS (& ETP):
» eAMS enables the generation and delivery of 1.6M electronic prescription messages per week at all of Scotland’s 1000 GP Practices and used in all 1200 Pharmacies. This improves patient safety through assurance for patient and medication item selection and allows for significant efficiencies to be achieved in payment processing ( £3.2M+ pa in efficiency savings for National Services Scotland.)
Chronic Medication Service eCMS
» eCMS improves the care of patients with long term conditions through a systematic approach to their care, enables eligible people to register with a community pharmacy of their choice, to have a personalised Pharmaceutical Care Plan record created and monitored and to have ‘serial’ prescriptions to be created to cover up to a years worth of medication. The medication will then be dispensed and monitored in their registered pharmacy. Reduces patient visits to GPs and reduces the number of paper prescriptions plus improves medicines management & reduces the drugs budget.
Minor Ailment Service eMAS
» eMAS aims to support the provision of direct pharmaceutical care within the NHS by community pharmacists to members of the public with a common self-limiting condition. enables eligible people to register with a community pharmacy of their choice and have their common conditions treated, including prescribing, by their community pharmacist on the NHS without the need to visit a GP and enabled by a revolutionary remuneration process
LOOKING FORWARD TO A BETTER FUTURE
SOME IDEAS FOR THE FUTURE
Payment process
PatientRegistration
Service
ePharmacyMessage
Store
InformationServicesDivision
ePay rules engine
Scanning and message processing
PharmacyCare
Record
Complianceblister pack technology ???
Telepharmacy Electronic Dispensing and Payment Processing for NHS24, OOH Pharmacy & Pandemics – Trial withUniversity of Aberdeen
ECS PCRs
ECS + PCRs arethe makings of anational patient summary record
Remote Electronic Prescribing (iPrescribe) mobile prescribing and pharmacy services – prototype 2011/12
Delivering beneficial change and efficiency gains and using innovative ways of sharing, developing and implementing to benefit the full patient journey
End to End Medicines & Compliance Management in NHSS – better dispensing and Pharmacy care information systems…add secondary care ePrescribing and compliance product to provide a unique medicines management service improving patient care and reducing costs through reducing re-admissions to secondary care and managing the drugs budget
• Test of change demonstrators commenced March 2011 following introduction of PEONY2…
• Enabling technology being fully utilised
• Aligning with local improvement initiatives eg CMR in Angus, Case Management and ACP’s across Tayside..
• Envisaged benefits across Patient Access, Service Redesign and Patient Experience:
1. Drive effective attendance at A&E
2. Reduction in unscheduled bed days
3. Effective discharge models
4. Focus on the right patients
5. Increase value multi-disciplinary team time
6. Net CRES of £1.5-2.0m per annum.
NHS Tayside BSU Dashboard Test of Change
Safe Effective Timely
Efficient Equitable Patient Centred
INTEGRATED CARE(VIRTUAL WARDS) - THE BENEFITS
• Next future state workshop brought together over 70 integrated care professionals and patient groups…
• Followed up be local sessions in CHP areas…
• NHS Tayside worked with partners to develop new HPM toolset – PEONY2
• Test of Change Demonstrators set up in each CHP
• Wider collaboration with Social Care, Voluntary Sector and Social Care
• Align outcomes with LDP, HEAT and Reshaping of Older People’s services
INTEGRATED CARE(VIRTUAL WARDS) - THE APPROACH
SUMMARY
• A whole system approach is key..
• Identify high impact projects and prioritise resource..
• Fully align with LDP and national outcome requirements
• Quality improvement with associated CRES takes priority..
• Early engagement of whole system stakeholders essential..
• Build on best practice evidence and focus on reducing unwarranted variation…
• Small steps, quick wins…
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