Integrated Care
Programme (ICP)
Locality Hubs
Model of Care for Frailty
30th January 2014
Context – Integrated Care Programme & Locality Hubs
•
ICP forms part of CCG’s Strategic Commissioning Plan
•
A major component is the design of a new Locality Hubs
model of care for frailty
•
Full service launch planned for April 2016
•
Fully commissioned service launched by April 2017
•
First phase in Woking
1
Context - drivers for change
• Ageing population, people living longer & more
people living with chronic conditions
• Cost & demand pressures
• Overreliance on hospitals & residential care
• Not enough focus on prevention & early
intervention
• Disconnect between social & medicalised care
• Fragmented delivery of services leading to
duplication & a lack of coordination
Fully aligned with recommendations
in the 5 Year Forward Review
• GPs as mainstay of the local care system –
wider Primary Care, delivered at scale
2
We started with a hypothesis…
~30%
of people in an acute bed at any one time never
needed an acute admission
~30%
of people in an acute bed are receiving no active
care & are waiting to be discharged
~30%
of people have challenges that are social and
rooted in isolation rather than medical needs
We have most (if not all) of the services
we need to provide best possible care for
our population
3
We need to…
• Create greater confidence & capability to keep people
safe and well at home, and in the community, without the
need for acute admission…
• …by introducing primary care physician leadership into
the out of hospital environment for medical care…
• …to better integrate services around our patients….
• …and take a more proactive approach to the care delivery.
4
Our hypothesis led us to two key ambitions
Less pressure
on the acute
sector
Better outcomes
& quality of life
1) No one should be in
an acute bed because
they are frail
&
2) No one should
become frail if they can
be helped to stay well
Improved care
quality & patient
experience
Optimised
health & social
care resources
More costeffective and
better value care
5
We’ve created 3 ‘frailty domains’ based on people’s needs
Frailty domains
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
Examples of need
•
•
•
Mobility and stability
Nutrition and hydration
Continence
•
•
Dementia and rationality
Depression and anxiety
•
CV disease with
•
•
Respiratory Disease
Neurological Disorders
– Diabetes
– A. Fib. / CVD
– PVD
•
There are many
definitions of frailty (E.g.
Edmonton scale) and all
capture elements of
physical, mental and
general wellbeing
•
The system support
needed to help a given
patient will depend on the
degree of need, the
individual’s ability to cope
with their circumstances
and the degree of family /
friend support available
6
We’ve quantified the target patient cohort by segment
Hub scope
Managed
Transition
Managed
Transition
Independent
Managed
Transition
Managed
Transition
Adaptive
Assisted
Dependent
~5k
~4.7k
~5.3k
EOLC
=
~15k
Criteria used to estimate target population by segment
• >75 & identified by GPs as Frail using Edmonton Scale
• Identified as at risk from functional decline & avoidable admission e.g.
•
•
•
•
Advanced lung function and breathing problems
Progressive neurological problems, including Dementia
In-dwelling catheters
Advanced cardiac disease
• Includes:
•
•
Nursing & residential home residents
EoL
7
Frailty domains cut across segments creating a ‘matrix of need’
Hub scope
Managed
Transition
Independent
Managed
Transition
Adaptive
Managed
Transition
Assisted
Managed
Transition
Dependent
EOLC
Frailty domains
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
8
These needs will be addressed by 7 service lines spanning each
domain & segment which together form part of a person’s care plan
Locality Hub
Independent
Adaptive
Assisted
Dependent
EOLC
Frailty domains
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
9
u
Adherence & Persistence
“I do the things that keep me well and I will do them for the long term”
INTERVENTION
Coaching,
training &
education
Well-being
classes
EXAMPLE ACTIVITIES
•
Patient: nutrition, hydration, alcohol and smoking,
hygiene, catheter care, coaching, shared decision
support, patient rehab, manual handling advice
•
Carer: care plan understanding, available support
learning, best practice learning
•
Staff: technical training, shared decision making,
motivational interviewing
•
Exercise classes (mental / physical; regular / trial)
•
Meals (at the Locality Hub)
10
v
Adaptive Environment & Assistive Technology
“I get the tools I need to keep me mobile, enable me to function day to day
& manage my own health”
INTERVENTION
Electronic
Devices
EXAMPLE ACTIVITIES
•
•
•
Mobility
Aids
Home
Adaptions
Remote monitoring & access (BP, warfarin, lung function,
safety, CPAP, telecare, BAS, suction, movement pattern, eprescribing, e-carte
Reminder aids (text, email, phone call), pill dispensers
Sensory aids (e.g. hearing aid)
•
Walking aids, splints and supports, assistive devices for
ADL, other aids
•
Home assessments
•
Advice on home environment – safety checks
•
Bathing equipment, lifts, hoists, ramps etc.
•
Meal preparation support
11
w
Medical Monitoring & Testing
“I have the regular check-ups I need to stay well & get treatment quickly
when I need it”
INTERVENTION
EXAMPLE ACTIVITIES
Regular
Check-ups
•
•
•
GP led check-up
Nurse led check-up (Practice Nurse/Healthcare Assistant)
Pharmacist led check-up
Specialist
Consultation
•
CV, Respiratory, Neurological disorders, Geriatrician,
Psychiatry, Podiatry, other
•
•
•
•
•
Blood pressure & hypertension
Hearing
Gait
Visual Acuity
Memory
•
•
•
•
•
Continence
Skin Assessment
Bloods & Urine tests
Bladder screening
Spirometry
•
•
•
•
Catheter replacement
Stoma Care
Infusion treatment
Sigmoidoscopy
•
•
•
•
•
Endoscopy/Colonoscopy
Fluoroscopy
Pressure sore care
Epidural steroids
IV Care
Diagnostics
& Screening
Minor Elective
Procedures
12
x
Medication Management
“I’m on the medications that best suit me, I know how to use them
properly & I’m reviewed regularly”
INTERVENTION
Medication
Review
Dispensing
EXAMPLE ACTIVITIES
•
Review of drug portfolio, drug-disease interaction, side
effect and A/I barrier
•
Pharmacist supported chronic medication dispensing and
intravenous treatment
13
y
Carers, Family, Friends & Community Support
“I make best use of the resources around me & my carers are supported to help me”
“I feel supported in my caring role and get support to have a life outside caring”
INTERVENTION
Information &
signposting
EXAMPLE ACTIVITIES
•
•
•
•
•
Assessment for •
carer support
Carer support
& training
•
•
•
•
Local community centres and faith groups
Voluntary opportunities
Support to use Surrey Information Point
Neighbourhood schemes
Food banks etc.
Carers assessment and advice
Signpost to local carer groups and services
Registering with carers emergency respite services
Practical care advice and training
Dementia café
14
z
Emotional Resilience
“I feel happy & able to cope with my circumstances & I know where to get
help when I need it”
INTERVENTION
Individual
Support
Group
Support
EXAMPLE ACTIVITIES
•
•
•
•
•
Named care coordinator
Telephone outreach
Befriending
Personal coaching – activation
Counselling
•
•
•
Meeting at the hub
Good neighbour schemes
Use of community centres
15
{
Transitions
“I know what to do when things change, & the people that know me & my
circumstances are there to support me”
INTERVENTION
Crisis
Management
Rapid
Response
Discharge to
Assess
EXAMPLE ACTIVITIES
•
Single point of contact
•
Immediate management of acute episode / exacerbation
•
•
•
•
2 hour response service
Same day response service
Wound management
Outpatient specialist consultation for new condition
•
Proactive in-reach into A&E and hospital to pull people
through the urgent care system
•
Rehabilitation
16
Locality Hub – conceptual model (one-stop-shop)
A physical building next to a community hospital providing an integrated frailty service for
people & their carers with all locality GP practices and services operating in a network
X
Locality Hub
Assessment, Care Coordination & Care Planning
Place of residence
e.g.
• Home
• Nursing Home
• Residential Home
• Extra Care Housing
Self Care
Care packages
People are referred to the Hub
from local services based on
flags for high risk & formal
screening at GP surgeries
Transport
Hub out-reach
u
v
w
x
y
z
{
Adherence & Persistence
Adaptive Environment & Assistive Tech.
Hospital
Medical Monitoring & Testing
Medication Management
Carers, Family, Friends & Community Support
Emotional Resilience
Transitions
Support services
Diagnostics
Pharmacy
Hub out-reach into
hospital to proactively
pull people through the
urgent care system
Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector
17
Indicative high-level roadmap
14/15
15/16
March
March
16/17
March
17/18
Implementation Plan in development
Woking
Pilot Live
Woking
Thames Medical
3 Locality Hubs
(fully operational)
SASSE
Develop
Service
Specification
All Localities
Run Procurement
(Service fully
commissioned)
18