Integrated Care – Where next?

Sasha Karakusevic

Starting high, aiming higherWe have achieved substantial

improvements for our community and receive positive feedback from patients and the public

Both the Care Trust and Foundation Trust were finalists in the HSJ PCT/Acute Trust of the year in 2009

But we know we can and must do better

Q2 BCBV sets baseline

The community journey

1991 Whole district trust

1992-7 GP fund-holding

2000 Integrated Care Network plan

2005 Torbay Care Trust

2009 Integrated Care Organisation pilot

Key lessons and hard choices Partnerships

Innovation

Managing the system Nurses and workforce Diagnostics and decision support 24/7 versus local Facilities, equipment and co-ordination

What has Mrs Smith experienced?1991 Working in Brixham

1995 Her mother needs a hip replacement, spends 2 weeks in Exeter having waited 12 months for surgery. Has a stroke 1 month later and spends 30 days in Torbay and 60 days at Paignton before discharge to a nursing home for 6 months. Dies.

2000 Retires. Husband has MI, waits for 3 weeks in hospital before transferring to London for surgery.

2008 Husband develops heart failure and dies 18 months later following 4 admissions

What would happen today? Mother has hip replacement 3 months after

seeing her GP. Date arranged to enable holiday with daughter pre-op. Enhanced recovery and VTE prophylaxis mean mum home 3 days post-op without complications.

Husband has chest pain. Calls 999 and has angioplasty 74 minutes later. Changes lifestyle.

Couple living happily and enjoying grandchildren.

The new challenge2009 2019 Change

Population 140000 160000 +20000Estimated non-elective admissions

37000 44000 +7000

Cash for non-elective admissions

£67m £67m +0

Cash per case

£1825 £1525 -£300

No change!Add £13m

£82 eachSay £500 per familyAnd this in only 25% of the health budget

Needs are changingCondition No.

Condition Name New CodingNew Weight

Old Weight

1 Acute myocardial infarction I21, I22, I23, I252, I258 5 1

2 Cerebral vascular accident

G450, G451, G452, G454, G458, G459, G46, I60-I69 11 1

3 Congestive heart failure I50 13 1

4 Connective tissue disorder

M05, M060, M063, M069, M32, M332, M34, M353 4 1

5 Dementia F00, F01, F02, F03, F051 14 1

6 DiabetesE101, E105, E106, E108, E109, E111, E115, E116, E118, E119, E131, E131, E136, E138, E139, E141, E145, E146, E148, E149

3 1

7 Liver disease K702, K703, K717, K73, K74 8 18 Peptic ulcer K25, K26, K27, K28 9 19 Peripheral

vascular disease I71, I739, I790, R02, Z958, Z959 6 1

10 Pulmonary disease J40-J47, J60-J67 4 1

11 Cancer C00-C76, C80-C97 8 2

12 Diabetes complications

E102, E103, E104, E107, E112, E113, E114, E117, E132, E133, E134, E137, E142, E143, E144, E147

-1 2

13 Paraplegia G041, G81, G820, G821, G822 1 214 Renal disease I12, I13, N01, N03, N052-N056,

N072-N074, N18, N19, N25 10 215 Metastatic cancer C77, C78, C79 14 316 Severe liver

disease K721, K729, K766, K767 18 317 HIV B20, B21, B22, B23, B24 2 6

10-19

20-49

What should we be dreaming about today to meet this challenge

?

Imagineering

b. 1928, lives forever

Integration is part of the solution

Excite, delight, simplify

Experience is growing

Preventative

Actions taken to avoid onset of known conditions

Immediate Intervention

Services in community which prevent admission to acute

Acute

Safe and efficient management of condition during acute intervention

Reablement

Services provided to maximise independence following acute admission or crisis

Palliative

Providing high quality care during end of life and enabling patients to die in place of choice

Virtual Pooled Budget for Older Peoples’ Care

Assistive Technolo

gy to support COPD

patientsEmergenc

y Care Practition

ers supportin

g falls

RACE Clinics

Primary &

secondary care

Medical Model

Emergency

Admission to

Hospital for

complex conditionsHospital Discharg

eCo-

ordinators

Community

Hospitals Medical

Evaluation

Orthopaedic Pathway

COPD/CCF/

Dementia in

Nursing Homes

End of life care Training

Pro-active care for Mr and Mrs Smith Self care when possible Tele-health support for high risk

periods Packages of care optimised to

maximise benefits Pro-active intervention when

markers indicate increasing risk

And for the care team

Investments to optimise capacity of local care settings and teams

Efficient support to optimise decision making and promote flexibility

Real time feedback of results and alerts accelerates improvement in outcomes

Virtual activity Specialists support frontline teams

What does this means for Mrs Smith?2020Getting more frail and forgetful. Husband has diabetes

and some heart failure. Daughters live in London and Scotland

Local support network in place (based in local nursing facility) to respond to issues detected by home monitoring system. Mr Smith has not needed to visit practice or hospital due to real-time monitoring and medication management system.

Daughters can support care through video link and access to shared records

What does it mean for us?