Frail and Elderly
Complex Care Case Management
Locally Commissioned Service
(LCS)
Dr Lance Saker
CCG Governing Body member and
Clinical Lead
Role of the LCS within the FE Programme
• Supports improved identification of frail patients with
complex needs.
• Improves the co-ordination of care for those patients.
• Supports delivery of an integrated model of care.
• Supports a reduction in use of unscheduled health and
social care
• Is the underpinning of the whole FE programme.
Role of General Practice in the FE Programme
1. Identification and Assessment
•
•
•
•
Regularly review patients on lists.
Enter suitably frail patients onto the frailty register.
Record a full frailty assessment
Record a comprehensive care plan.
• Use the designated Camden EMIS templates.
2. Case management of patients on register
• Decide on level of need – in practice or hub?
• In practice – MDT case management in place.
• Hub – refer on and ensure delivery of actions arising.
Working with the people of Camden to achieve the best health for all
Role of General Practice in the FE Programme
3. Practice Based MDT Meetings
• Must include patient’s case manager, GP and community team
rep.
• Meet at least quarterly.
• Patients can be stepped down from case management if risk of
unscheduled need reduces.
4. Training and education
 All clinicians at the practice to undertake a learning module.
 One member for peer education at MDT Hub every 6 months.
 Practices to undertake adult safeguarding training.
Working with the people of Camden to achieve the best health for all
The CCCM LCS Process Map
Revisions to original LES
 A Complex Care Management LES was in place 13/14.
 Was accompanied by a Risk Stratification ES.
 New LCS incentives practices to do a detailed
assessment of need, to further increase referrals to the
MDT Hub.
 Removed the requirement to undertake audits.
 Payment for case management is being replaced by
proactive home visiting and in-practice consultation.
Working with the people of Camden to achieve the best health for all
Payment Schedule
Component
Payment
Comment
All fields marked “LCS” on the
relevant
template
must
be
completed to incur payment
Assessment undertaken and care plan
completed on template with evidence of
£75 per patient
MDT input
MDT team meetings to discuss cases
To qualify, the practice must have
£100 per practice, per month at least 10 patients on their FR
(max. 12/year)
6 monthly attendance at Hub MDT peer
review education sessions
£150
per
attendance
practice
Only one person per practice will
per be paid to attend but as many as
wish to may attend
Working with the people of Camden to achieve the best health for all
Impact of the LCS
Variation by practice
Variation in care plans
Further impact
Potential Frailty Gap
Future Developments
• Federated GP Practices
• Proposed development of an FE Integrated
Practice Unit
• Taking forward the ‘Vanguard’ possibilities
Working with the people of Camden to achieve the best health for all
The Future circa 2017/18?
Diagnostics
Key in year changes
•
Integration with acute
•
Commission GP front
end front end hub
GP Front End (Hub)
8am-8pmcommission
Specialist
services
Link to GP
Core GP
service
GP
Federation
Admin Hub
OOH/111
Elective
GP (Spoke)
8am-8pm
Camden
Community
Service (CCS)
Unscheduled Care
8am-10pm
• Minor injury
Outreach to
home
MDT
working
Chronic Disease
Management
• Community LTC Hub
• Diagnostics
• Ambulatory Care
• Link to GP OOH/111
• Specialist clinicians
Chronic Disease
Management
Community Services
• Advice and Guidance
• Cross-cutting
• services
• Community and Social Care teams
• Rehabilitation
• Link to community beds
• Rapid Response teams
A&E
• Outreach to local population
• In-reach to hospital
Nonelective
Secondary care
Continuous focus on prevention
Underpinned
by:
Workforce development via partnership work across providers
Shared / interoperable records system (CIDR)