what we need to achieve: our
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NHS Stoke on Trent WM AHSN patients, clinical priority: Term • 270,000 registered 54 Long GP practices Conditions • 2 new GP practices and GP led Health Centre Professor Ruth Chambers OBE, GP planned for&2009 Clinical telehealth lead, Stoke-on-Trent CCG • Some of theHonorary most professor deprived wards in England, Keele & Staffordshire • 5 PBC clusters closely Universities aligned with the Local Authority neighbourhood areas AHSN Long Term Conditions Priority Integrated Care Adoption & Diffusion Education & Training Wealth Creation Digital Delivery Clinical trials Mental health Drug safety LTCs It’s about the basics improving delivery of best practice care for long term conditions via patient empowerment, integration & innovation Best clinical practice & shared management Improved QUALITY of clinical care Tech 3 Most people with any long term condition have multiple conditions (eg Scotland) Multimorbidity is common in UK – The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions – More people have 2 or more conditions than only have 1 People with multimorbidity are much more likely to have emergency and potentially preventable admissions 600 Annual admission rate per 1000 patients 500 479 Potentially preventable admission Other emergency admissions 400 342 318 300 242 200 200 151 151 115 100 100 85 74 64 51 31 0 20 3 0 5 1 9 14 21 2 3 4 34 47 5 6 No of conditions 7 8 9 10+ International evidence shows that people with multimorbidity experience more problems with the coordination of their care Right treatment for LTC, right delivery, right time, right team, right intensity Personal responsibility & self care Digital delivery can support the whole patient pathway Supporting people at home Enhanced support at home Specialist acute input Manage Crisis Effectively Manage step down from acute effectively Enhanced support at home Supporting People at Home Home Home Support* Long term hypertension Smoking Cessation Long term vital signs monitoring Care Homes Pain Mment Medicines Management “Worried Well” INR Weight loss motivational messages Health self assessment Sexual health Crisis Unstable Hypertension EMAS unstable vital signs monitoring Newly diagnosed hypertension Oncology Medication Reminders for: - Hypertension / Ashma inhaler / pain management Paediatric ashma COPD Diabetes (type1& 2) Neurology Speech therapy Acute Pregnancy induced hypertension Virtual Wards Gestational diabetes Intermediate care COPD CHD Alcohol support Learning disabilities Mental health behaviour Mental Health appt & medication reminders/ supportive messages Diabetes physiotherapy Monitoring of pre op patients to reduce cancelled operations Daily living/ medication reminders for people Palliative care carer with Aspergers/autism support/wellbeing Out patient acute specialist follow up Falls prevention Support early discharge Heart Failure Trf of care DNA management Step down facilities Unstable vital signs monitoring Medication management Support Long term hypertension As * Smoking Cessation Long term vital signs monitoring Care Homes Pain Mment Medicines Management “Worried Well” INR Weight loss motivational messages Health self assessment Sexual health Palliative Care HF Nurse HF Nurse Support ECHO Primary Care Core GP Service Practice Nurse District Nurse Urine Analysis Full Blood Community Matron GP Patient Self Care Weight Management Fluid Restriction Symptom Monitoring Lifestyle Changes WMAHSN LTC stakeholder consultation –so far LTCs Themes Asthma COPD Hypertension Heart failure OA AF Diabetes & obesity Integration Empowering patients Shared management Upskilling patients Program Interventions Beacon sites; rollout GP/social care integration Patient upskilling eg avatar, apps Education Clinical champions; patient champions Adoption & diffusion Web resource Flo telehealth- exemplars Digital delivery Computerised decision support Wealth creation Virtual patient information leaflets /app Databases: successful LTC innovations, patient stories, shared management plans Helping patients to help themselves £ free to txt all my teams Readings & answers Opt-in/out, prompts, questions, feedback, advice, education Alerts if needed 12 Working with industry Designed for collaboration Enabling an industry & academia ecostructure, building on the core 13 Working with CCGs: eg risk profiling – underpinning evaluated innovations Level 3: High Complexity Case Management Level 2: High risk Disease/Care Management Low cost, large-scale: ‘simple telehealth’ Level 1: 70-80% of LTC population Self care support/management Focus on patient perspectives of clinical conditions? Enriching self care as agreed shared management Helping people to help themselves – as agreed with their clinicians – throughout all tiers of care Looking forward ?
