INTEGRATING CARE ACROSS
MID NOTTINGHAMSHIRE
Transforming Care for People with Long Term
Conditions and the Frail Elderly
Our financial challenge
Across Mid Nottinghamshire
•
The total cost of the physical health and social care economy is £398m.
•
The 19m funding gap from 2012-13 could increase to at least £70m, and possibly
be more than £100m by 2018.
5 Year Financial gap = £70m
Current Financial gap = £19m
600
10 year Financial gap = £140m
400
300
200
Total funding: Health & social care
Y12
Y11
Y10
Y9
Y8
Y7
Y6
Y5
Y4
Y3
Y2
0
Y1
100
Today
Millions of pounds (£)
500
Total cost
July 2013
2
We have a vision for the next five
years
INTEGRATED CARE
Locality teams
Self-management
100%
Risk profiling
Third sector
provision
Quality of life
Long Term Condition
Management incl Cancer
Primary Care
SHIFT
LEFT
COMMUNITY CARE
ACUTE CARE
Consultant-led services
Specialist teams
Specialty Clinic
Planned procedures
ICU
0%
£1
£10
£100
£1,000
£5,000
Patients and healthcare professionals
told us that services were….
•
Disease specific – patients often under the care of 3 or more different
teams / individuals
•
Fragmented, with poor communication between teams
•
Isolated – Silo services with health and social care working in isolation
•
Confusing – HCPs and patients don’t always know what services are
available and how to refer to them
•
Frustrating, with lengthy referral times / waits
•
Inconsistent, with patients falling through the gaps
•
Limited, particularly in relation to a lack of out of hours cover – only
option for some is 999
•
Overloaded, especially primary care and community services
•
Reactive – care is based around crisis management
Our Vision
To work collaboratively with our partners across the health economy
to:
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Transform the way we deliver care by creating a whole system, fully
integrated hospital, community, primary and social care model.
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Improve outcomes for patients with Long Term Conditions and the
frail elderly.

Create access to better, more integrated care outside of hospital
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Reduce unnecessary hospital admissions
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Enable more effective working of healthcare professionals across
provider boundaries.

Address the significant economic challenges ahead
Our Partners
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Sherwood Forest Hospitals Foundation Trust
Health Partnerships ( Community and Mental
Health Services Provider)
Nottinghamshire County Council
Newark and Sherwood District Council
Newark and Sherwood CVS
Self Help Nottingham
Patients
Carers
Integrating the management of
cancer as a long term condition
This is Albert
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76 years old
Ex Miner
Heart Failure
Diabetes
Hypertension
History of alcohol abuse
He is married to Mary who is 74. She has osteoporosis,
diabetes and arthritis. They live in a 3 bed ex council
house in a rural area with a dog called Fred and have
lost touch with most of their friends. They have 3
children who all live away.
Principles of the New Approach
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Radical – Completely redesign the system across the entire health
economy.
Work in partnership with all partners organisations
A focus on proactive care to anticipate and prevent crisis
Primary Care at the heart of the system – A community based model
Systematic profiling and risk stratification of the whole population and
systematic streaming into dedicated services.
Integration of care across the health and social care economy
Personalised care designed around the patients’ needs
Care planning and shared decision making to become systematically
embedded into every day practice
Increased access to services around the clock and out of hours
Recognition of the need to invest and commitment to do so
Risk Stratification
Risk Stratification
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Using risk profiling software – The Devon Tool
available to all GPs in all practices.
Combined Predictive Model developed and utilised
in Torbay ICP.
Demonstrated 86% accuracy in predicting future
admission
Utilised in 2 ways
 Service
Planning and commissioning
 Practice Level Patient Identification
Mid Nottinghamshire Integrated Model of Care for Long Term Conditions
Workforce Development, Training and Education
Smoking Cessation, Health Promotion and Self Care
Low RISK / Complexity
Level
1
Devon Tool for Systematic Risk Profiling to identify risk
Patients step up and down as risk profile changes
21% - 100%
Public Health
Population
wide
Prevention
Proactive Self Care Support
and Management in Primary
Care
Risk score recorded and
reviewed annually
Disease
awareness
campaigns
Active Case Finding
Social
marketing
Accurate diagnosis
Education
Health
promotion
Schools
HIGH RISK / Complexity
2
6-20%
Proactive Disease Management by
General Practice supported by
specialist community services and
teams
Telehealth / Telecare
Support to Self Manage
Community Specialist
Services and clinics with
MDT support
Education Programmes
Annual Review
Information Prescriptions
Care Planning
Education relevant to patients
needs
3
Care Planning and individualised
Care plan
Disease Register
Specialist Medication reviews
Anticipatory Care
Remote monitoring via tele health
where appropriate
Disease prevention and
Health promotion
Top 0.5%
0.6-5%
Intensive disease / case
management by
specialist teams as part
of the MDT
Care Planning and
individual personalised
care plan
Planned Hospital
Admission for those who
need it and facilitated
discharge via intermediate
care to reduce LOS
4
Community Matron /
Virtual Ward as part of
Multidisciplinary Team
(Community Geriatrician,
GP, Social Care,
Therapists, Rehab,
Domiciliary )
Care Planning and
individual personalised
care plan
Disease Specialist Input
where required from
specialist community
teams ( COPD, Diabetes)
Telehealth and Tele Care
Psychological Support
Planned hospital
admission , proactive in
reach and facilitated
discharge where needed
Co-ordinated Social Care
Care Coordinator / Named Lead
Admissions Avoidance
Special Patient Notes / 24/7 Access to specialist support
Integrated Care
Locality Based Integrated Care Teams
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3 x locality based Multi-disciplinary teams / Virtual Wards
North ward launched Dec12, West Ward March 13, Newark
Ward April 13
Each team comprising: ( all WTE posts)
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Community Matrons
District Nurses
Occupational Therapist
Physiotherapist
Mental Health Worker
Social Worker ( directly commissioned from LA by the CCG)
Healthcare Assistants
Voluntary / Third Sector Workers – Part of the MDT
Ward Coordinator/ Manager
Underpinned by ………..
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Specialist case management teams ( Level 3) for COPD, Heart
Failure and Diabetes.
Community based clinics ( CVD, COPD, Diabetes) with
commissioned consultant specialist support
Community nursing teams and GP practice teams integrated and
aligned with each of the 3 ward teams throughout
Care Homes integrated into the Virtual wards – people treated as if
they were in their own home.
In the process of commissioning Community Geriatrician support
Increased provision of Intermediate care beds ( Step up and Step
down)
Procurement of new Crisis Response Service ( June)
Community
Specialist Teams
Newark and Sherwood Integrated Team Model- LOCALITY VIEW
Voluntary Services
There will be three
localities , North, South
and Newark.
The number of Virtual
wards per locality will be
dictated by the population
and size. In areas where
there is more than 1
virtual ward some roles
will be shared between
wards.
Named
Community
Geriatrician
Dietetics
Tissue
Viability
Community
2 Matrons
Community Physiotherapist
Nurses
Occupational Healthcare
Therapist Assistants
Medicines
Management
Named
Community
Oncologist
GP
GP
GP
Podiatry
Virtual Ward
Core Team
Voluntary
Services
Falls Team
Extended Team
Support across all localities
Crisis Response / Rapid
Intervention Service
Intermediate Care
Comm
munity
Pharmacy
Mental Health
Professional
Monthly Risk
Stratification
EMAS/ CNCS/ OOHs
Continence
Named Specialist
Nurse
COPD
HF
Diabetes
Cancer
Social
Worker
Community
Support
Workers
Ward CoOrdinator
Diabetes/ COPD/
Heart Failure/ Cancer
Level 3 Case
Management
Step Up Step Down
between level 3 and
level 4 ( Virtual ward)
Key
GP Practices/
Primary Care
Locality specific
Virtual Ward /
MDTs x 3
Cross locality
support teams
working across
all localities
and specialist
disease
management
teams
CCG wide
services
Specialist
Community
Teams – disease
specific. Level 3
case
management
Mid Nottinghamshire Integrated Model of Care for Long Term Conditions
Workforce Development, Training and Education
Smoking Cessation, Health Promotion and Self Care
Low RISK / Complexity
Level
1
Devon Tool for Systematic Risk Profiling to identify risk
Patients step up and down as risk profile changes
21% - 100%
Public Health
Population
wide
Prevention
Proactive Self Care Support
and Management in Primary
Care
Risk score recorded and
reviewed annually
Disease
awareness
campaigns
Active Case Finding
Social
marketing
Accurate diagnosis
Education
Health
promotion
Schools
HIGH RISK / Complexity
2
6-20%
Proactive Disease Management by
General Practice supported by
specialist community services and
teams
Telehealth / Telecare
Support to Self Manage
Community Specialist
Services and clinics with
MDT support
Education Programmes
Annual Review
Information Prescriptions
Care Planning
Education relevant to patients
needs
3
Care Planning and individualised
Care plan
Disease Register
Specialist Medication reviews
Anticipatory Care
Remote monitoring via tele health
where appropriate
Disease prevention and
Health promotion
Top 0.5%
0.6-5%
Intensive disease / case
management by
specialist teams as part
of the MDT
Care Planning and
individual personalised
care plan
Planned Hospital
Admission for those who
need it and facilitated
discharge via intermediate
care to reduce LOS
4
Community Matron /
Virtual Ward as part of
Multidisciplinary Team
(Community Geriatrician,
GP, Social Care,
Therapists, Rehab,
Domiciliary )
Care Planning and
individual personalised
care plan
Disease Specialist Input
where required from
specialist community
teams ( COPD, Diabetes)
Telehealth and Tele Care
Psychological Support
Planned hospital
admission , proactive in
reach and facilitated
discharge where needed
Co-ordinated Social Care
Care Coordinator / Named Lead
Admissions Avoidance
Special Patient Notes / 24/7 Access to specialist support
Systematisation of Self Care
Systemisation of Self Care and Care
Planning
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Support to increase patient involvement in their own care
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Education
Confidence
Access to relevant support networks
Consultative care planning – we will do “with” and not “to”
“No decision about me without me”
Not just about giving information
Improving and enhancing provision of carer support, information
and education
Inclusion of voluntary sector services to improve patient/carer
support
Self Care is EVERYONES responsibility during EVERY patient contact
The evidence shows that it is the
cumulative effect of each of these
intervention and actions that
makes a difference…..
We have to do them all
What Have We Achieved to Date?
KPI Monitoring for PRISM – 10% reduction in emergency admissions for COPD, Diabetes and
Heart Failure
Rolling 12 Month Total for Emergency Admissions with a Primary
Diagnosis of COPD, Heart Failure or Diabetes (Adms upto Aug 2013)
N&S North
250
200
N&S West
Newark and Trent
Newark Team
Go Live
North Team
Go Live
150
100
50
West Team Go
Live
0
24
FOUNTAIN MEDICAL CENTRE
BARNBY GATE SURGERY
HOUNSFIELD SURGERY
LOMBARD MEDICAL CENTRE
BALDERTON PRIMARY CARE CENTRE
COLLINGHAM MEDICAL CENTRE
May12 - Jul12
HILL VIEW SURGERY
BLIDWORTH SURGERY
RAINWORTH HEALTH CENTRE
30
BILSTHORPE SURGERY
FARNSFIELD SURGERY
SOUTHWELL MEDICAL CENTRE
MAJOR OAK MEDICAL PRACTICE
CLIPSTONE HEALTH CENTRE
MIDDLETON LODGE PRACTICE
Newark & Sherwood Emergency Admissions per 1,000 patients by Practice
May 13 to July 13
N&S North Locality
N&S West Locality
Newark and Trent Locality
Emergency Admissions per 1,000 Patients - May13 - Jul13
35
May13 - Jul13
25
20
15
10
5
0
25
What Have We Learned?
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Stakeholder engagement is key and must not be underestimated – invest in
the time up front
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GP buy in critical – Financial support to get things going
Organisational sign up and commitment at senior level across all stakeholders
Needs to be CCG core business not a bolt on.
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Dedicated project management – Needs to be someone's day ( and night!) job
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Investment in community services
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Historic underinvestment meant we started from a low baseline
Staff training and skills development
Cultural as much as clinical
IT, Data and IG challenges – Expertise and investment required from day 1
Integrated Care on its own will not achieve the desired outcome
Whole system redesign is required to underpin the model including urgent
care
Recognition that the outcomes wont necessarily be achieved immediately
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Transformation vs QIPP
Benefits
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In our Pilot, our admissions were reduced by 19%
Joint Visits – addressing medical and social issues
The team are contactable !!
Any problems can be resolved quicker,
issues/problems are addressed that may
previously have not been highlighted
Patients like it!
PRISM isn't a service – It’s a way
of life !!
What Next?
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Further development and training of the Integrated Care
Teams and the MDT approach
Proactive in reach for facilitated discharge
Emergency care pathways – working with OOHs providers to
develop pathways to avoid unnecessary conveyance
Embarking on “Year of Care” training for all clinicians
Implementation of new self care strategy
Development and implementation of cancer pathways and
support
Joining up the IT
Scale up and roll out across mid Nottinghamshire as part of
major Transformation Programme
The New Integrated Urgent & Proactive
Care Model for Mid Nottinghamshire
We have a moral imperative to make the
system fit for purpose for the changing
demands of the population – people want
to see joined up services and a system
that is less complicated to access,
retaining universal access
Helping to shape future health and social care in Mid Nottinghamshire
COMMERCIAL IN CONFIDENCE
What do we mean by integrated care ?
“Care, which imposes the patient’s perspective as
the organising principle of service delivery and
makes redundant old supply-driven models of care
provision. Integrated care enables health and social
care provision that is flexible, personalised, and
seamless.”
Helping to shape future health and social care in Mid Nottinghamshire
COMMERCIAL IN CONFIDENCE
Integration – a means to an end, not an end in itself
• Integrated care must focus on those patients for whom
current care provision is disjointed and fragmented
• Effective system leadership must exist
• The interaction between generalist and specialist
clinicians must promote real clinical integration
• There must be integrated information systems
• Financial and non-financial incentives must be aligned
Helping to shape future health and social care in Mid Nottinghamshire
COMMERCIAL IN CONFIDENCE
The consequences of being ambitious are less scary
than not being ambitious enough….
Helping to shape future health and social care in Mid Nottinghamshire
COMMERCIAL IN CONFIDENCE
Principles underpinning the design of the proactive and urgent care system
• Significant interdependencies between proactive care and urgent care, hence the
decision to develop a joint business case
• None of the interventions can be considered or developed in isolation
• Services will be available 7 days a week and, where necessary, 24/7
• Care will be provided in a persons home wherever possible; the design focuses on
reducing the need for admission to hospital/residential care, but, where this is
required, seeks to expedite the return home as quickly as possible
• Design spans health and social care, with joint funding and joint commissioning
where appropriate
• Utilises learning from elsewhere
• The patient and the carer is at the centre of all design (Albert)
• Provider “Blind”
• Patients will receive / have access to the same care / services regardless of where
they are domiciled ( ie care home vs Own Home )
• Mental Health out of scope per se but all interventions designed with provision for
interface
December 2013
35
Key:
Proactive and Urgent care model
Care in the patient’s home
Crisis
notification
Self Care
Proactive
care
Urgent
Care
SICT
Care navigation
Away from the
community
Towards
community
Acute care
Self care
Maintain independence
Self Care Hub
PRISM plus
Healthy living & wellbeing
Care Navigator
Proactive care
Risk Stratification
MDTs
GP/OoH
Determine
necessary care
package and
deploy services
EMAS
Social Care
Virtual wards / MDTs
Specialist Intermediate Care
Team
Acute care
Single Front
Door
A more responsive primary care service
Acute Medical Emergency
Crisis Response Team
Intermediate care in the home
Low level
support
Enhanced
support
Intensive
support
A&E/ MAU/ WARD
Back door
Bedded Intermediate Care
Discharge
coordination
Communicating effectively with the public
Low level
support
Enhanced
support
Intensive
support
Self Care
• New Self Care Hub which will bring together all self-care activity and support
across mid Nottinghamshire and act as a single point of access to relevant support
for both healthcare professionals and patients.
• It will enable patients to access information and practical support and advice to
better manage their long term condition, to be signposted to self-care options, to
make positive life style changes and learn essential skills.
• The hub will be staffed by trained support workers overseen by a small
management team with additional support provided by trained volunteers who
will:
• Work as part of the Virtual Ward / Integrated Care teams to provide self-care
support directly to patients in the community
• Work within the hub itself to provide telephone support, signposting, and
information to patients and healthcare professionals.
• The hub will also be used as a venue for specific training and education
programmes for both patients and HCPs and also be utilised by other
organisations wishing to provide or host self-care or care planning training and
education events
• Oversight and delivery of structured disease management education programmes
December 2013
37
Virtual Ward MDT
• Expansion of PRISM Virtual wards to 8 across Mid Notts
• Proactive care to pts at high risk of admission (identified via Devon Tool)
• Rehab and reablement care for patients post crisis or post discharge
• Work closely / aligned with Specialist Intermediate Care Team
• Care planned and appropriate resources deployed within the team/s to meet the
level of input / support required by individual patients dependent on their specific
needs at any given point
• Access to “fixed” beds for patients who require higher levels of support
• Step Up / Step Down
• MCH / Fernwood/ Existing Beds
• Care Homes
• Continual review to facilitate timely step down through the model
• Interface with Mental Health Intermediate Care Services
December 2013
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Care navigator
• Professional staff will phone when they have a patient with an urgent care need
and they are looking for community alternatives to admission or to support a
discharge from hospital or care home
• Calls will be answered by a clinician (nurse, paramedic, SW) with rigorous call
handling standards
• The service will operate from 8.00 - 22.00 each day as it is unlikely that effective
navigation would be possible in the overnight period
• A Directory of Services will support the service; this will include a capacity indicator
for services as well as their criteria for access, etc
• Calls can be patched through to secondary care consultant staff for clinical
discussions on the management of a patient
• A GP will also be available for clinical discussion
• By the end of the call the service will have agreed with the caller the package of
care to be delivered and the timeframe within which it must be in place
• Admin team will make necessary referrals with safety net procedure sin place to
ensure that care plan is delivered as expected
December 2013
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Crisis Response
• A function within the specialist intermediate care team
• Currently mainstream services cannot always mobilise services quickly enough to
maintain the person at home
• A team of trained but unqualified staff who can respond to referrals and provide
care within 2 hours; clinical input will be via the specialist intermediate care team
• Available 24/7
• Able to support patients who are currently at home as well those who may have
attended A&E but do not require hospital admission
• It is expected that:
• 90% of patients will be transferred to the main specialist intermediate
care service, other mainstream services or discharged within 3 days
• 100% of patients will be discharged or transferred within 7 days
• Likely to be based at Kings Mill Hospital and Newark Hospital
December 2013
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Enhanced Intermediate Care Model
• Intermediate care is the vehicle / enabler which will control the flow in and out of
hospital and drive the right patient into the right place.
• Three Key Elements:
• Admissions avoidance ( Proactive care and Step Up)
• Support for early discharge
• Rehabilitation and Reablement
• Evidence shows that patients have better outcomes when managed in their own
homes – esp FOP’s
• National policy direction to move away from fixed beds and increase provision of IC
in the community
• Care in the patients home as default with use of fixed beds only when level of
support required precludes the option – ( ie requires 24 hour nursing or medical
supervision)
• Move away from and balance current focus on step down to increase focus on
step up to stop people getting to hospital in the first place.
December 2013
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Specialist Intermediate Care Team working across three key areas
• Front Door to support discharge to assess or admission plans
• Discharge planning on admission and coordination and delivery of discharge on
the wards
• Provision of post discharge support / and care in the community including crisis
response
• Up to 14 days intensive rehab
• Hand over to Virtual ward / MDTs for longer term support
• Staff rotating across all three functions
• Access to “fixed” beds for patients who cannot be managed in their own homes
• MCH / Fernwood/ Existing IC Beds
• Care Homes
December 2013
42
Front door at A&E
• Integrated booking in and triage systems between current PC24 and A&E service
• Enhanced team at front door to include GP, specialist intermediate care, ANP for
frail older people; increased consultant paediatrician presence
• Signpost patients to other services following symptom relief and reassurance
• Maximise see and treat
• Maximise ambulatory care (upper quartile performance)
• Enhanced function within specialist intermediate care to provide immediate
December 2013
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Fit with National Policy
• Addresses the proposals in the national review of urgent and emergency care,
phase 1 (with the exception of designation of A&E departments)
• In line with the new enhanced service for the GMS contract
• Design for intermediate care reflects recommendations made in National Audit of
Intermediate Care 2013.
December 2013
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Benefit / Impact ( over 5 years)
Activity
• Non-elective Admissions ( SFHT)
• A&E Attendances (SFHT)
• Occupied/Excess bed days (SFHT)
• Non –elective readmissions ( all providers)
• Demand for Long Term Residential care
Reduction of 19.5%
Reduction of 15.1%
Reduction of 12.6%
Reduction of 10%
Reduction of 25%
Above activity delivers in line with Blueprint assumptions
Financial
• Re- Provision costs slightly lower than Blueprint
• Financial benefits being worked up and will be shared within formal business
cases being presented to Governing Bodies in February 14.
December 2013
45
Thank You
Any Questions?
For further information please
contact:
Jan Balmer
Associate Director – Integration and
Unplanned Care
jan.balmer@newarkandsherwoodccg.nhs.uk
Tel: 07734 296846
Transforming Care for People with Long Term
Conditions