‘Integrated Care Teams’QIPP Long Term Conditions
Dr J JohnNational Clinical Associate in LTC/QIPP
Department of Health
19th July 2012Kent and Medway LTC Programme
Statistics Long term conditions represent… The average
annual health cost…
170,000 people die prematurely of
long-term conditions each
year
Significant variation across PCTs exists in
emergency hospital use
60%
The Case for Change
252%
rise just in Diabetes by 2050188%
increase in the number of patients with multiple LTCs by 2013
rise in over 65 year olds by 2050
Current Spend2011
Projected Spend 2016
Pay: 3+ Long Term Conditions Date:
2011Amount in Words: Nineteen Billion Pounds
Signed:
__________
£19,000,000,000
Pay: 3+ Long Term Conditions Date:
2016Amount in Words: Twenty Six Billion Pounds
Signed:
___________
£26,000,000,000
The Case for Change
No health care system is sustainable in the face of this tsunami of need
The systems perspective
The patient perspective
QIPP LTC WorkstreamP
rim
ary
dri
vers
: Risk Profiling
Integrated care teams at locality level
Systematic empowerment of patients to self manage
Integrated teams
• Improved health status, reduced weight and improved diet1,4
• People were most likely to be alive, living independently at home6
• Improved symptoms and behaviours5
• Improved health status & mental well-being. Outcomes for lower cost3,7
Source: (1) Kasper “A Randomized Trial of the Efficacy of Multidisciplinary Care in Heart Failure Outpatients at High Risk of Hospital Readmission”. Journal of the American College of Cardiology Vol. 39, No. 3, 2002
Source: (2) Griffiths. “Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme”. Thorax 2001;56:779–784
Source: (3) van den Hout “Patient team care nurse specialist care, inpatient team care, and day arthritis: a randomised comparison of clinical multidisciplinary care in patients with rheumatoid”. Ann Rheum Dis 2003 62: 308-315
Source: (4) Capomolla et al. “Cost/utility ratio in chronic heart failure: comparison between heart failure management programme delivered by day-hospital and usual care” J Am Coll Cardiol 2002; 40: 1259-66
Source: (5) Opie, Doyle & O’Connor “Challenging behaviours in nursing home residents with dementia: a RCT of multidisciplinary interventions” Int J Geriatr Psychiatry 2002; 17(1):6-13
Source: (6) Stroke Unit Trialists’ collaboration “Organised inpatient care for stroke” Cochrane Library, issue 2, 2004
Source: (7) Ahlmen et al “Team vrs non-team outpatient care in rheumatoid arthritis” Arthritis Rheum 1988; 31(4): 471-9
The Vision in ONEL
Population Size: 236,000Population Size:
180,000
Population Size: 270,000
Population Size: 227,000
41 GP Practices
54 GP Practices
45 GP Practices
47 GP Practices
Coordinated care for patients and carers in the community
Optimal patient experience and clinical outcomes
Lower cost, better productivity
Whole system change (1,000,000 patients)
Outline / Aims of the Project
• Providing Integrated Care services where “the patient receives the care that they want and nothing more; the care that they need and nothing less”.
• Partnership working between the GP practice, Social services and provider services.
• Avoids duplication of services.
Aims:Integrated Teams
Aims: Integrated Teams
• Provides proactive management of long term conditions and social needs.
• Prevents avoidable hospital admissions because of robust planned care and patient education
• Reduction in permanent admissions to residential and nursing homes
Component Parts of ICM
ONEL :Integrated Care Team
Therapies
Acute care
specialists
End of Life
Mental health
Voluntary Sector
Drug & Alcohol services
*Named District Nursing Sister and allocated Band 5 Community Nurse
GP PRACTICE x7
COMMUNITY MATRON
COORDINATOR
SOCIAL WORKERS
OT
DISTRICT NURSES*
LD SUPPORT(virtual)
MH SUPPORT(virtual)
GP PRACTICE x7
COMMUNITY MATRON
COORDINATOR
SOCIAL WORKERS
OT
DISTRICT NURSES*
LD SUPPORT(virtual)
MH SUPPORT(virtual)
CLUSTER 1 CLUSTER 2 CLUSTER 3 CLUSTER 4 CLUSTER 5 CLUSTER 6
The Model:Co located
Community Planned Care
(health & social care)
Access
Integrated Case Management Overview
Identify Service User
High Risk patients identified via Health Analytics and Clinical Expertise
The Integrated Care Team
- GP- Community Matron- Social Worker- District Nurse- Integrated Case Coordinator- Additional Specialist / Voluntary Sector as needed.
Case Conference & Care Plan
Fortnightly meetings at practice level High risk patients discussed and care plan Implemented
Care Delivery
Care delivery by Integrated Team as coordinated by Integrated Care Coordinator with the patient
Ongoing Care
Onward Referral
Self Management
Care Plan Review
Single point of access
Provides 24/7 Nursing / Reablement to prevent hospital admissions and support early discharge
Works in partnership with Out of Hours GP services to prevent hospital admission
Works in partnership with the London Ambulance Services in full to prevent hospital admission
Admits Patients to step up community beds to provide short term interventional care
Rapid response underpins the integrated care model and provides nursing /reablement unplanned care 24/7 up to 14 days to prevent hospital admissions and promote early
supported discharge
Community unplanned care (health & social care)
Rapid Response
Experience based design videos to co-own/produce new ways working
Workstreams- coproductionVisits undertaken to more than 140
GP practices in ONELStakeholder engagement events
organised for each boroughMeetings with each stakeholder –
social services, community provider, acute trust, Public health, Voluntary
ONEL strategy sessionsFeedback from patients / pilot sites
at B&D
Outline case presented to each stakeholder
Research activity to identify best practice
Significant time spent by the QIPP team in shaping the model of care.
DH support/Visits to other sites for learning
Business cases, Practice support,Estates
Governance agreements/documentsModelling activity to determine
savings
Stakeholder engagement Planning/ Implementation
Planning and Implementation
Case Study 1
Patient BM
80 year old F in top
1% who needed
more intervention
as time progressed
MHX: AF, CCF,
Hypertension, PVD,
COPD under 4
specialist teams
(London and local)
Social: Lives alone,
help from niece,
carers going in twice
a day
Pre IC:
No feed back from disciplines frequent hospital admissions no team approach to patient poor outcomes depression
Post IC:
More joined up working More effective use of services in the community Patient feels more supported Trying to address key issues (pain) and more accountable ownership of particular patient problems via specialist teams in the community
Overall Outcomes
Quality Outcomes Over 1300 patients with MDT care plans in place
132 GP practices, 3 local authorities, 2 acute trusts and 1 community provider
delivering the model of care ( Integrated Care Coalition)
Improved co-ordinated care by multi-disciplinary teams and reduced duplication
Every patient has a nominated and dedicated coordinator to coordinate personalised
care
Rapid access to social care as needed through direct referral to social care
Social Care Improvements
• Reclaiming social work• Shared risk taking• Improved referral pathway• Locality working – personalisation spin offs• Hospital in-reach• Reduction in admissions to residential care• Significant increase in SDS performance
Overall Outcomes
Financial Outcomes
Reduction in length of stay for patients with LTC in comparison to 10/11. 12%
reduction in Waltham Forest and a 9% reduction in Redbridge , 10% in B and D
Reduction in the number of referrals to nursing / residential homes
Increased timeliness of care packages
Reduction in the number of safeguarding referrals
Overall Outcomes
Operational Outcomes
Transformational community nursing workforce development
Co-location of health and social care teams in B&D and Redbridge building “high trust”
partnership teams
Establishment of strong collaborative working with primary/ community teams and secondary
care to support patients across the pathway
Full roll out of integrated data platform to integrated health intelligence from acute, GP, social
care and community data sources across all boroughs to target appropriate patients for
model of care
Improvement in staff retention in services
Now a site for – ‘Year of Care Pilot’ for the DH
Support
• Website, Update, Resources, Virtual programme, LTC Commissioning Pathway
• Local Support-
• National Coach (DH) and Queens Nurse- Sharon Lee
Future
The best way to predict the future is to create it
Peter Drucker