ProMISE
The Bromley Programme
Sam Merridale, Programme Lead
June 2012
ProMISE
Proactive Management and Integrated Services for the Elderly
The Local Context
• Large ageing population >16% in 2011
• Diabetes, cardiac and respiratory commonest
cause of ill health
• Carers and dementia probably under
recognised
• Current service delivery often fragmented &
reactive
ProMISE
Proactive Management and Integrated Services for the Elderly
The Vision
Improve the health of our older
population with complicated health &
social needs in Bromley
ProMISE
Proactive Management and Integrated Services for the Elderly
The Goals
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Inform patients and promote independence
Identify most vulnerable & over 65
Design care plan around the patient’s needs
Manage their care through coordinating
services effectively
ProMISE
Proactive Management and Integrated Services for the Elderly
The Objectives
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Develop a tool to identify most vulnerable
Create a cohort of people “virtual ward”
Design patient-centred care-plan
Deliver quality service-coordinated, targeted
and appropriate
• Promote self-care and education for patient &
carers
• Improve communication between care-givers
ProMISE
Proactive Management and Integrated Services for the Elderly
ProMISE
Proactive Management and Integrated Services for the Elderly
Outcomes
• Improve clinical outcomes, reducing
unplanned admissions and length of stay in
hospital
• Improve patient’s experience, broadening
their understanding of their health needs and
self-care measures
ProMISE
Proactive Management and Integrated Services for the Elderly
Developing a Culture Shift
• Key driver is to improve care for our older
population
• Need for better respect, improved
understanding, shared commitment,
opportunities for learning & support->
effective collaborative working
ProMISE
Proactive Management and Integrated Services for the Elderly
The next step-Phase One
• 2 community matrons & 2-3 GP Practices
• Testing out the pathway with existing services
• Results & progress will inform and enable us
to improve and refine services based on active
cases
• Start education programme in primary care
ProMISE
Proactive Management and Integrated Services for the Elderly
Programme Implementation
• Managed process
• Programme management team – meet weekly
• Agree programme structure, priorities and
case for change
• Engagement – critical to success
ProMISE
Proactive Management and Integrated Services for the Elderly
Programme Governance
• Programme Board – responsible for all
decisions and moving the programme forward
• Clinical Advisory Group
• Stakeholder Reference Group
• Programme Implementation Group
ProMISE
Proactive Management and Integrated Services for the Elderly
Accountability
• Health and Wellbeing Board – Financial
oversight of shared budget
• Bromley Clinical Commissioning Executive
• Bromley, Bexley, Greenwich Programme –
Clinical Strategy Group
ProMISE
Proactive Management and Integrated Services for the Elderly
Stakeholder Engagement
• Primary care clinicians
• London Borough of
Bromley
• Bromley Healthcare
• South London Hospitals
NHS Trust
• Oxleas Trust
• London Ambulance
Service
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Bromley Links
Bexley CCG
Greenwich CCG
NHS SL Cluster
St Christopher’s
Voluntary Sector
EMDOC
… etc
ProMISE
Proactive Management and Integrated Services for the Elderly
Interesting issues!!
• Case finding – using risk stratification, but also
clinical knowledge
• Data sharing – across organisational
boundaries, and critical to success
• Metrics for evaluation – must be consistent
with others
• Telehealth – explore the principles of how this
will support true integrated care – it’s not just
about expensive gadgets
ProMISE
Proactive Management and Integrated Services for the Elderly