1

North East Leicester PbC Cluster

Extended Integrated Care Team

Dr Nitin Joshi – GP & Project Lead Clinician

Tracey Shepherd – Locality General Manager

Michelle Beasley – Project Manager, Personalised Care Plans

2

Hypothesis

Does a whole systems approach to integrated care lead

to better quantative and qualitative outcomes?

3

NEL Commissioning Group The wider context

• 7 Practices

• Population 44,777

• 16.1% Patients Over 65 vs. PCT 11.6%

• Disease Prevalence rates higher than PCT average• CHD • Heart Failure• Stroke• Hypertension• COPD• Asthma• CKD

4

Timeline

• November 2007 – Unique Care Pilot• March 2010 – Presented Business case to

expand project• July 2010 – funding received and EICT

Project commenced• August 2010 – Link with QIPP LTC

workstream

SIMPLE SYSTEMS

‘one size fits all’

‘mono’-morbidity

Good mental health

Well defined groups

Defined interaction with secondary care

COMPLEX SYSTEMS

Need individual care plans

Multi-morbidity

Mental health complications

Poorly defined groups

Poorly defined interaction with secondary care

SIMPLE SYSTEMS

‘one size fits all’

COMPLEX SYSTEMS

Need individual care plans

Integrated team

Mental health worker

Risk stratification

Acute care group primary care physician

Personalised care plans

‘mono’-morbidity

Good mental health

Well defined groups

Defined interaction with secondary care

Multi-morbidity

Mental health complications

Poorly defined groups

Poorly defined interaction with secondary care

7

All patients of NEL cluster

Best practice, Map of Medicine and Medicine Management

Risk Stratification Tool Pilot and other intelligence to identify patients at risk patients

Practice NurseSocial Workers

District Nursing

UHL (Acute Sector)Proactive Admission Management & Discharge Planning

Early DischargePathways

Community Matrons Mental Health Worker

Appropriate Treatment

In reach nurse

Patient Pathway

GPsExtended Integrated Care Team

8

The Business Case Focus

2008/09 NEL Cluster Higher than PCT average spend for:

• Total Non Elective Admissions• Excess Bed Days• Prescribing

• The KPMG 6 identified conditions• Cellulitis• Lower Respiratory Tract (without COPD)• Lower Respiratory Tract (with COPD)• Congestive Heart Failure• UTI• Dehydration

9

Handbook example

10

Handbook example

11

Handbook example

12

Case and Load Management Meetings

13

Activity Targets

Forecast Activity TargetsForecast Activity 2009/10 1st Year 2nd Year

    10% 20%

    £ £

Cellutitus 53 5 11

Lower Respiratory tract infections without COPD 223 22 45

Lower Respiratory tract infections with COPD 243 24 49

Congestive Heart Failure 33 3 7

UTI 120 12 24

Dehydration 3 0 1

6 conditions identified by KPMG as a potential PCT saving of 35% of Acute cost 675 68 135

       

Prescribing NA NA NA

Excess Bed days (5% year one and 10% year 2) 3230 161 323

Activity   161 323

14

Summary 6 Months (April 10- Sep 10)      

Condition Actual TargetDiff from Target

Respiratory Conditions without COPD 98 101 -3

Respiratory Conditions with COPD 102 110 -8

Congestive Heart Failure 12 15 -3

Dehydration 4 2 2

UTI 52 54 -2

Total ALL 292 305 -13

Summary - Non-Elective admissions against Target for 6 Priority Conditions for First 6

Months ( April 10 - September 10) All Providers.

Evidence so far

15

Evidence so far

Cluster Performance

0

200

400

600

800

1000

1200

1400

Goal 1086 1086 1086 1086 1086 1086 1086 1086 1086 1086 1086 1086

Actual 994 1023 1212 1065 918 1093 981 1107

Apr May J un J ul Aug Sep Oct Nov Dec J an Feb Mar

Emergency non-elective admissions

Evidence so far

17

Personalised Care Plans

• Patient held & led record• Communication Tool• Holistic approach • Support for self management• Developed by a stakeholder group• Excellent ‘fit’ with the pilot • QIPP programme helped gel together

18

What they say

Zoe Harris - Community Health Nursing Lead

Anne Forde – Adult Social Care“Personalised care planning is the only way to work as it puts the individual at the heart of their support. It focuses the workers on the individuals, goals, wishes feelings, needs and what's important to that person to support them and enable well being”.

Mark Pierce – Commissioner NHS Leicester City

“Personalised care plans have great potential to contribute to improvements in patient outcomes. They can offer commissioners a window on the workings of the services they commission.  They also offer an insight into how patients experience their illnesses and as such can be of interest to any commissioner.”

“My experience of PCP’s for level three patients is that they can be an effective way to ensure quality care for individuals with LTC’s particularly when they include the patients own self management plan when they experience an exacerbation of their condition and also to record their wishes for end of life care”.

19

What they say

Diana Osbourn – patient“It is fantastic that my wish to have more control and responsibility over management of my Long term Condition has at last been acknowledged and that I will be able to really work in partnership with my GP & Health Specialists to prioritise what is important to me”

Patient“Less time wasted on duplication and reducing my visits to the GP/Doctor, saves time & money for me & the NHS - it’s a winner all round! “

John Cook – patient"I am sure that the joined up thinking, at the heart of this project will help NHS become more effective and efficient benefiting practitioner and patient”

Dr Maini, EICT Project GP

“A cohesive way of working that benefits patients and health professionals alike”

20

What they say

Project Lead – Personalised Care Plans

The reaction from patients and voluntary groups

especially has been one that “We are really ready for this,

and are looking forward to help manage our conditions the way that works best for us, working in partnership

with our key workers “

Social Worker Bhavna Maher EICT Project“Services will benefit greatly if health and

social care professionals work in partnership”

’’

Integrated Care Project “Excellent to see how joined up thinking and working can save £’s as well as lives – and that it is actually working!”

21

Where Next

• Handbook• Web pages/ YouTube• Risk Stratification• Recruitment of MHNS• Recruitment of 2 In Reach Nurses• Project survival in the current changing

climate

2

Hypothesis

Does a whole systems approach to integrated care lead

to better quantative and qualitative outcomes?