promise proactive management and integrated services for the elderly promise the bromley programme...
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![Page 1: ProMISE Proactive Management and Integrated Services for the Elderly ProMISE The Bromley Programme Sam Merridale, Programme Lead June 2012](https://reader036.vdocuments.us/reader036/viewer/2022062321/56649ee55503460f94bf50f5/html5/thumbnails/1.jpg)
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
ProMISEThe Bromley Programme
Sam Merridale, Programme LeadJune 2012
![Page 2: ProMISE Proactive Management and Integrated Services for the Elderly ProMISE The Bromley Programme Sam Merridale, Programme Lead June 2012](https://reader036.vdocuments.us/reader036/viewer/2022062321/56649ee55503460f94bf50f5/html5/thumbnails/2.jpg)
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Local Context
• Large ageing population >16% in 2011• Diabetes, cardiac and respiratory commonest
cause of ill health• Carers and dementia probably under
recognised• Current service delivery often fragmented &
reactive
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Vision
Improve the health of our older population with complicated health &
social needs in Bromley
![Page 4: ProMISE Proactive Management and Integrated Services for the Elderly ProMISE The Bromley Programme Sam Merridale, Programme Lead June 2012](https://reader036.vdocuments.us/reader036/viewer/2022062321/56649ee55503460f94bf50f5/html5/thumbnails/4.jpg)
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Goals
• Inform patients and promote independence• Identify most vulnerable & over 65• Design care plan around the patient’s needs• Manage their care through coordinating
services effectively
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Objectives
• Develop a tool to identify most vulnerable• Create a cohort of people “virtual ward”• Design patient-centred care-plan• Deliver quality service-coordinated, targeted
and appropriate• Promote self-care and education for patient &
carers• Improve communication between care-givers
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
![Page 7: ProMISE Proactive Management and Integrated Services for the Elderly ProMISE The Bromley Programme Sam Merridale, Programme Lead June 2012](https://reader036.vdocuments.us/reader036/viewer/2022062321/56649ee55503460f94bf50f5/html5/thumbnails/7.jpg)
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Outcomes
• Improve clinical outcomes, reducing unplanned admissions and length of stay in hospital
• Improve patient’s experience, broadening their understanding of their health needs and self-care measures
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Developing a Culture Shift
• Key driver is to improve care for our older population
• Need for better respect, improved understanding, shared commitment, opportunities for learning & support->
effective collaborative working
![Page 9: ProMISE Proactive Management and Integrated Services for the Elderly ProMISE The Bromley Programme Sam Merridale, Programme Lead June 2012](https://reader036.vdocuments.us/reader036/viewer/2022062321/56649ee55503460f94bf50f5/html5/thumbnails/9.jpg)
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The next step-Phase One
• 2 community matrons & 2-3 GP Practices• Testing out the pathway with existing services• Results & progress will inform and enable us
to improve and refine services based on active cases
• Start education programme in primary care
![Page 10: ProMISE Proactive Management and Integrated Services for the Elderly ProMISE The Bromley Programme Sam Merridale, Programme Lead June 2012](https://reader036.vdocuments.us/reader036/viewer/2022062321/56649ee55503460f94bf50f5/html5/thumbnails/10.jpg)
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Programme Implementation
• Managed process• Programme management team – meet weekly• Agree programme structure, priorities and
case for change• Engagement – critical to success
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Programme Governance
• Programme Board – responsible for all decisions and moving the programme forward
• Clinical Advisory Group• Stakeholder Reference Group• Programme Implementation Group
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Accountability
• Health and Wellbeing Board – Financial oversight of shared budget
• Bromley Clinical Commissioning Executive• Bromley, Bexley, Greenwich Programme –
Clinical Strategy Group
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Stakeholder Engagement
• Primary care clinicians• London Borough of
Bromley• Bromley Healthcare• South London Hospitals
NHS Trust• Oxleas Trust• London Ambulance
Service
• Bromley Links• Bexley CCG• Greenwich CCG• NHS SL Cluster• St Christopher’s• Voluntary Sector• EMDOC• … etc
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Interesting issues!!
• Case finding – using risk stratification, but also clinical knowledge
• Data sharing – across organisational boundaries, and critical to success
• Metrics for evaluation – must be consistent with others
• Telehealth – explore the principles of how this will support true integrated care – it’s not just about expensive gadgets