integrating care across mid nottinghamshire transforming care for people with long term conditions...

INTEGRATING CARE ACROSS MID NOTTINGHAMSHIRE Transforming Care for People with Long Term Conditions and the Frail Elderly

July 2013 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. 2 5 Year Financial gap = 70m10 year Financial gap = 140m Our financial challenge

Quality of life We have a vision for the next five years 1101001,000 ICU ACUTE CARE 0% COMMUNITY CARE Self-management Long Term Condition Management incl Cancer Third sector provision Primary Care 100% Consultant-led services Specialist teams Specialty Clinic Planned procedures INTEGRATED CARE Locality teams SHIFT LEFT 5,000 Risk profiling

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 dont 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: Transform the way we deliver care by creating a whole system, fully integrated hospital, community, primary and social care model. Improve outcomes for patients with Long Term Conditions and the frail elderly. Create access to better, more integrated care outside of hospital Reduce unnecessary hospital admissions Enable more effective working of healthcare professionals across provider boundaries. Address the significant economic challenges ahead

Our Partners 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 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 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

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

Devon Tool for Systematic Risk Profiling to identify risk Top 0.5% 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 0.6-5% Intensive disease / case management by specialist teams as part of the MDT Telehealth / Telecare Community Specialist Services and clinics with MDT support Care Planning and individual personalised care plan Planned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS 6-20% Proactive Disease Management by General Practice supported by specialist community services and teams Care Planning and individualised Care plan Support to Self Manage Education Programmes Annual Review Specialist Medication reviews Anticipatory Care Remote monitoring via tele health where appropriate Patients step up and down as risk profile changes 21% - 100% Proactive Self Care Support and Management in Primary Care Risk score recorded and reviewed annually Active Case Finding Disease Register Accurate diagnosis Information Prescriptions Care Planning Education relevant to patients needs Disease prevention and Health promotion HIGH RISK / ComplexityLow RISK / Complexity Smoking Cessation, Health Promotion and Self Care Admissions Avoidance Public Health Population wide Prevention Disease awareness campaigns Social marketing Education Health promotion Schools Workforce Development, Training and Education Co-ordinated Social Care Mid Nottinghamshire Integrated Model of Care for Long Term Conditions Special Patient Notes / 24/7 Access to specialist support Care Coordinator / Named Lead 1 2 3 4 Level

Integrated Care

Locality Based Integrated Care Teams 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) 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 .. 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)

GP 2 Community Matrons Community Nurses Occupational Therapist Community Support Workers Ward Co- Ordinator Physiotherapist Social Worker Monthly Risk Stratification Named Community Geriatrician Named Specialist Nurse COPD HF Diabetes Cancer Dietetics Tissue Viability Continence Crisis Response / Rapid Intervention Service Voluntary Services Community Specialist Teams Diabetes/ COPD/ Heart Failure/ Cancer Level 3 Case Management Step Up Step Down between level 3 and level 4 ( Virtual ward) Community Specialist Teams Diabetes/ COPD/ Heart Failure/ Cancer Level 3 Case Management Step Up Step Down between level 3 and level 4 ( Virtual ward) Linked to Extended Team Support across all localities Virtual Ward Core Team Podiatry EMAS/ CNCS/ OOHs Intermediate Care Access to & Support from 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 Newark and Sherwood Integrated Team Model- LOCALITY VIEW Mental Health Professional Healthcare Assistants Named Community Oncologist 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. Comm munity Pharmacy Medicines Management Falls Team

Devon Tool for Systematic Risk Profiling to identify risk Top 0.5% 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 0.6-5% Intensive disease / case management by specialist teams as part of the MDT Telehealth / Telecare Community Specialist Services and clinics with MDT support Care Planning and individual personalised care plan Planned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS 6-20% Proactive Disease Management by General Practice supported by specialist community services and teams Care Planning and individualised Care plan Support to Self Manage Education Programmes Annual Review Specialist Medication reviews Anticipatory Care Remote monitoring via tele health where appropriate Patients step up and down as risk profile changes 21% - 100% Proactive Self Care Support and Management in Primary Care Risk score recorded and reviewed annually Active Case Finding Disease Register Accurate diagnosis Information Prescriptions Care Planning Education relevant to patients needs Disease prevention and Health promotion HIGH RISK / ComplexityLow RISK / Complexity Smoking Cessation, Health Promotion and Self Care Admissions Avoidance Public Health Population wide Prevention Disease awareness campaigns Social marketing Education Health promotion Schools Workforce Development, Training and Education Co-ordinated Social Care Mid Nottinghamshire Integrated Model of Care for Long Term Conditions Special Patient Notes / 24/7 Access to specialist support Care Coordinator / Named Lead 1 2 3 4 Level

Systematisation of Self Care

Systemisation of Self Care and Care Planning Support to increase patient involvement in their own care 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?

24 KPI Monitoring for PRISM 10% reduction in emergency admissions for COPD, Diabetes and Heart Failure North Team Go Live West Team Go Live Newark Team Go Live

25 Newark & Sherwood Emergency Admissions per 1,000 patients by Practice May 13 to July 13 Newark & Sherwood Emergency Admissions per 1,000 patients by Practice May 13 to July 13

What Have We Learned? Stakeholder engagement is key and must not be underestimated invest in the time up front 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. Dedicated project management Needs to be someone's day ( and night!) job Investment in community services 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 Transformation vs QIPP

Benefits 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 Its a way of life !!

What Next? 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

Helping to shape future health and social care in Mid Nottinghamshire COMMERCIAL IN CONFIDENCE 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 What do we mean by integrated care ? Care, which imposes the patients 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. COMMERCIAL IN CONFIDENCE

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.

December 2013 Principles underpinning the design of the proactive and urgent care system 35 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

Care Navigator Self care Self Care Hub Proactive and Urgent care model Acute care Care in the patients home Crisis notification Care navigationAcute care A&E/ MAU/ WARD Single Front Door Maintain independence Healthy living & wellbeing Acute Medical Emergency PRISM plus Specialist Intermediate Care Team Discharge coordination Proactive care Crisis Response Team Back door MDTs GP/OoH EMAS Social Care Determine necessary care package and deploy services Virtual wards / MDTs Intermediate care in the home Low level support Enhanced support Intensive support Risk Stratification Bedded Intermediate Care Low level support Enhanced support Intensive support A more responsive primary care service Communicating effectively with the public Urgent Care Proactive care Key: Self Care Away from the community Towards community SICT

December 2013 Self Care 37 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 Virtual Ward MDT 38 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 Care navigator 39 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 Crisis Response 40 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 Enhanced Intermediate Care Model 41 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 FOPs 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 Specialist Intermediate Care Team working across three key areas 42 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 Front door at A&E 43 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 Fit with National Policy 44 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 45 Benefit / Impact ( over 5 years) Activity Non-elective Admissions ( SFHT) Reduction of 19.5% A&E Attendances (SFHT)Reduction of 15.1% Occupied/Excess bed days (SFHT)Reduction of 12.6% Non elective readmissions ( all providers) Reduction of 10% Demand for Long Term Residential care 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.

Any Questions? Thank You

For further information please contact: Jan Balmer Associate Director Integration and Unplanned Care [email protected] Tel: 07734 296846 [email protected] Transforming Care for People with Long Term Conditions

integrating care across mid nottinghamshire transforming care for people with long term conditions...

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