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What have we learnt?

Jeremy Martin, Symphony Programme Director

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135,000 population, older age profile30,000 with long term conditions19 GP practices2 community hospitalsCommunity mental health team1 district general hospitalPoor public transportPredominantly small market towns and villages

About South Somerset

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Data

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78%~90k

18%~20k

4%~5k

~15%~£20m

~35%~£55m

~50%~£75m

% of population % of cost

Complex patients with many conditions

Less complex patientswith fewer conditions

Mainly healthy patients

Complex care hubs

Enhanced primary care

Proactive health and wellbeing support

Population segmentationand new care models

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Potential impact on GP financials: average1

South Somerset Practice

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Care model

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The Core Care Model – Enhanced primary careThe patient and health coach are supported by the wider care team and a number of care programmes and services.

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Town

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TEAMSCOMPLEX CARE

Neighbourhood

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District

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Acute

High Complexity

Medium Complexity

Low Complexity

No Complexity

Model resource & provisionSecondary Care with support from Extensivist and Nurse Practitioner

ExtensivistNurse PractitionerInvolvement from wider MDT & GP

GPComplex care nurseKey worker+/- Extensivist

GP

GPHealth CoachPractice Nurse

LEV

EL O

F N

EED

S

PROPORTION OF THE POPULATION

In reach support from Complex CareSupported discharge

Comprehensive ReviewUpdate care plan

Escalation plan Crisis intervention

Alternative to admission (planned)

Comprehensive Care PlanCo-ordination of services

Health CoachingAccess to Extensivist advice

Basic Care PlanHealth CoachingLifestyle advice

Chronic Health Registers

Self Care

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Impact

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Non-elective admissions down 7.5%

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Non-elective bed days down 15%

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Patient Activation Diabetes Prevention

• Through health coaching:

• Pre-diabetic to non pre-diabetic: 16-33%

• Diabetic to pre-diabetic: 20%

• Weight loss: >70%

• Minimum £1.6M annual saving

• Potential savings much larger

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Video – A day in the life of a Symphony GP

https://www.youtube.com/watch?v=-YBNikPmEBM&feature=youtu.be