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Local Authority and the NHS – working together in achieving Integrated Care in Hillingdon

Zac ArifICP Project Manager Hillingdon

February 2012

Zac.arif@nhs.net

Hillingdon

• Second largest of London’s 32 boroughs• Estimated 268,000 people with over 7% aged 65+ • Priorities include:

– Diabetes (higher than England average)– Elderly (population likely to increase by 8.5%)– Chronic Obstructive Pulmonary Disease and Heart Failure

• 47 GP practices

• Delivering a challenging programme of modernising services and approaches to service users

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Hillingdon: ~ 268,000

people

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Purpose of Integrated Care is to improve service user experience and outcomes by minimising organisational barriers between different services, and between services and commissioners

• In Hillingdon we want to:

• Focus on people with long term conditions (diabetes,75+, COPD,HF)

• Standardise the approach to care using best evidence

• Put the patient at the centre of their care

• Bring together health and social care professionals to share expertise to

better coordinate and improve care

• Make better use of the funds we collectively have.

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Our partners

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Benefits for Hillingdon

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Current Position in Hillingdon

• GP practices: 41 (out of 47) GP practices have joined

• 85% of Hillingdon residents covered

North Hillingdon MDG

HILLINGDON INTEGRATED MANAGEMENT GROUP

HILLINGDON INTEGRATED MANAGEMENT BOARD

Hayes and Harlington

MDG

Uxbridge and West Drayton

MDG

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Dr Kuldhir Johal, GP, IMG Co-chair Moira Wilson, Interim Deputy Director Social Care & Health, LB Hillingdon and IMG Co-chair

Maria O’Brien, Managing Director, Hillingdon Community Services

Joy Mitchell ICP Lead, LB Hillingdon, Social Services 

Claire Sheppard , Assistant Director of Operations, Hillingdon Hospital

Dr Angela Joseph, GP, MDG ChairHayes and Harlington Locality 

Graham Hawkes, Chief Executive, Hillingdon LINK,

Belinda Norris, Service Manager Older People's Services, LB Hillingdon

Dr Steven Reid, Clinical Director, Psychological Medicine, CNWL 

Dr Sagar Dhanani, GP, MDG Chair Uxbridge West Drayton Locality 

Angela Wegener, Chief Officer, DASH, Zac Arif, ICP Project Manager

Jonathan Turner, ICP Performance Manager Dr Ella Kosciesza (EK), GP, MDG Co-Chair North Hillingdon Locality

Dr Ritu Prasad, MDG Co-ChairNorth Hillingdon Locality

Professor David Sines CBE, Pro Vice Chancellor and Executive Dean Society and Health, Buckinghamshire New University

IMG Members

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How does Integrated Care work in practice?

Community pharmacist

Practice nurse

Social care worker

District nurse

GP

Community Mental Healthrepresentative

Patient Registry Risk Stratification

Care Delivery1

Case Conference

Performance Review

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Shared Clinical Protocols3

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1 Icons are illustrative only: Any number of other professionals may be involved in a patient’s care, a case conference or performance review

Each MDG holds a register of all patients who are part of the pathway – these patients are part of the Pilot

The MDG uses the ICP information tool to stratify these patients by risk of emergency admission

Each patient is then given an individual integrated care plan that varies according to risk and need

Patients receive care from a range of providers across settings, with primary care playing the crucial co-ordinating role and everybody 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, which will help plan and coordinate care

The MDG meets regularly to review its performance and decide how it can improve its ways of working to meet the Pilot goals2

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All providers in the MDG agree to provide high quality care as laid out in the Pilot’s recommended pathways and protocols

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Work Planning4

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List of participants at MDG meetings

Multi-Disciplinary Groups…

Group

Community matron

Practice

Practice

Nurse

Social Care

Representative

District nurse

Mental Health Specialist

GP

Primary Health Care Team

Social care Specialist

Acute Specialist

Community Mental Health Representative

Leadership and support

•Led by an MDG Chair

•Supported by an MDG co-ordinator

Key participants

•General Practitioners

•Acute Consultants

•Community clinicians

•Mental health Consultants

•Social care partners

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•Mobilisation of ICP Pilot Commenced June 2012

•As of January 2013, the ICP now covers 86% of Hillingdon population

•Diabetic and elderly care pathways rolled out at inception of Pilot

•COPD, coronary artery disease, atrial fibrillation and heart failure now developed and roll-out starts February

•41 (out of 47) General Practices in Hillingdon are part of the ICP.

Achievements in 2012/13: Key Milestones

Listening to all the people who participate in the ICP, there is encouraging enthusiasm and optimism that for the first time we have a means of working together to provide truly multidisciplinary patient focused care for those with long term conditions.

Acute Care Consultant

Listening to all the people who participate in the ICP, there is encouraging enthusiasm and optimism that for the first time we have a means of working together to provide truly multidisciplinary patient focused care for those with long term conditions.

Acute Care Consultant

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• 65% of attendees say they have changed their clinical practice as a result of attending a case conference.

• MDG survey – 91% of attendees at case conference report that they have developed relationships that improve the way they are able to care for patients.

• Attendance at case conference across the ICP has averaged 83% (100% SS).

• 67% believe that the advice they gave or received as part of a case conference would help to reduce non-elective admissions.

• MDGs help to appropriately direct and expedite referrals and appropriate actions. • Telephone survey of patients November 2012:

• 100% of patient discussed what was most important to them in managing their own health

• 68% of patients believe they received a good amount of information during these sessions

• 96% of patient think that having the care planning discussion has helped improve how they manage their health problem.

Achievements 2012/13 - survey

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Direction of Travel 2013/14

• Patient is at the centre of their care planning, thus evolving the case conference model to improve efficiency and utilisation of clinician time, and timely feedback to patients;

• Focussing on the quality of care planning, ensuring each patient gets the same standard of care across Hillingdon;

• Further breaking down organisational boundaries in terms of information sharing with patient consent;

• Moving to a model which plans care for all patients above a pre-determined risk stratification score rather than specific pathways that is truly integrated care across social and health care providers;

• Responding to the “Whole Systems Integrated Care” agenda and exploring moving towards a system of ‘shadow budgets’ as part of which providers have the opportunity to share cost and revenue information.

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Why support Integrated Care?

• Improve patient experience and reduce admissions so that patients can be cared for in the community. We have to control unscheduled admissions and A&E attendances – ICP is an effective way of doing this

• The evidence that ICP is changing clinical practice is strong, through multi-professional (MDG) meetings and shared learning

• There is a strong push from the NHS and from bodies representing patients to connect up different parts of the NHS and social care so that functions and roles are not duplicated - we fully acknowledge and support opportunity for more joined up working

• NHS Hillingdon /HCCG support ICP and have approved its Business Plan

• ICP is a way of bringing in new money to Hillingdon which can support innovative new services for patients working collectively with a common aim

Case study: avoiding unnecessary secondary care through improved awareness – a diabetic patient in Hillingdon was to be referred to bariatric services in secondary care because there was a belief that this was the only place that could provide dietetic advice. However the diabetic nurse present at the case conference confirmed that their service provided dietary advice to diabetic patients in a center located next door to the patients GPs surgery.

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Innovation Fund - £500K investment for introduction of new projects

• The “F” Word, Falls programme – identifies patients 75+ who have had a fall to reduce the risk of falls in the future

• Integrated Diabetes Team – provides diabetes education

• Assisted Discharge for the Frail and Elderly – a focussed period of rehabilitation for up to 5 days for those patients discharged from hospital with a history of falls, to ensure clinical and social support at home

• Psychological support for people with Long Term Conditions – comprehensive assessment and targeted psychological interventions for people with diabetes

• Community Nursing in Residential and Nursing Homes – 2 dedicated community nurses to engage with local care homes specialising in elderly care and dementia.

• All of the above to be taken forward in the coming months using current ICP funds

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Summary of 2012/13

• Review of leading qualitative indicators shows us to be in a position of strength.

• We are seeing positive changes at MDG and patient level, with clinical practice changing as a result of ICP and changes in the way patients are cared for.

• If clinicians are changing their clinical practice, and care plans are increasing the ability of patients to care for themselves, this will eventually translate into improvements in clinical outcomes and reduced hospital admissions in the medium and long-term.

• Expected areas of clinical impact include:

- Improved blood sugar control- Improved blood pressure- Improved cholesterol- Improved post-operative care after falls

“The ICP has provided my practice with an excellent opportunity to learn from

experienced consultants so that we can manage difficult

cases” – GP Uxbridge and West

Drayton MDG

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Key Features of the Business Plan 2013/14

Maximising the Potential of the ICP

•A focus on public involvement -increasing the public awareness of ICP in Hillingdon and involving patients in design of evolving ICP model from inception

•Supporting a system to move to a single integrated way of sharing information across providers within the ICP

•Improving the current risk stratification system

•Building on existing care pathways to add COPD and CHD

•Implementing v3 clinical templates

•Focus on quality in care planning

•Evolve case conference model to improve efficiency and utilisation of valuable clinician time

•Develop more mature performance management system with dashboard of KPIs

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Strategic Changes 2013/14

• Moving to a risk stratified approach across pathways• Build links with the mental health ‘shifting settings of care’

initiative.

Organisational form8

Organisational form8• Care planning to be developed so that it is integrated

across services and there is only one care plan per patient (alignment with Co-Ordinate My Care Programme).

Organisational form8

• Breaking barriers between health and social care organisations, hospitals and GP practices.

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Strategic Changes 2013/14

Organisational form8 • Implement a system of ‘shadow budgets’ as part of which providers have the opportunity to share cost and revenue information (NHS Mandate)

Organisational form8

• Moving to a more efficient and sustainable model for case conferences, potentially moving to a single case conference per each MDG covering a range of different conditions based on a risk stratified approach.

“Being part of the ICP project provides Age UK Hillingdon with an exciting opportunity working as part of a team of health and social care providers in Hillingdon, to achieve a shared vision. By weaving our services together, we will develop stronger links and a clear understanding of the contribution we each can make along the pathway so that our residents receive all the support they need to get the positive outcomes they want.” - Chris Commerford, CEO of Age UK Hillingdon

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Working with Commissioners to Redesign Services

• Greater role for MDGs/ Integrated Management Group’s in service redesign in 13/14

• MDGs are a great source of local expertise

Potential areas for service transformation:

• Development of an Outcome Based Specification to inform commissioning intentions for community services

• Setting future requirements for the clinical workforce

• Alignment of MDGs with the primary care transformation programme.

‘[Our MDG] is a brilliant forum for a multi-professional discussion which is paramount for provision of holistic care…and also to find pathways to work in a more financially efficient way.’- MDG Chair, Hillingdon

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Thank You