Frail and Elderly Complex Care Case Management Locally Commissioned Service (LCS) D r 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 Working with the people of Camden to achieve the best health for all 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. Role of General Practice in the FE Programme Working with the people of Camden to achieve the best health for all 3. Practice Based MDT Meetings Must include patients 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. The CCCM LCS Process Map Revisions to original LES Working with the people of Camden to achieve the best health for all 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. Payment Schedule Working with the people of Camden to achieve the best health for all ComponentPaymentComment Assessment undertaken and care plan completed on template with evidence of MDT input 75 per patient All fields marked LCS on the relevant template must be completed to incur payment MDT team meetings to discuss cases 100 per practice, per month (max. 12/year) To qualify, the practice must have at least 10 patients on their FR 6 monthly attendance at Hub MDT peer review education sessions 150 per practice per attendance Only one person per practice will be paid to attend but as many as wish to may attend Impact of the LCS Variation by practice Variation in care plans Further impact Potential Frailty Gap Future Developments Working with the people of Camden to achieve the best health for all Federated GP Practices Proposed development of an FE Integrated Practice Unit Taking forward the Vanguard possibilities Chronic Disease Management Community Services Unscheduled Care 8am-10pm Unscheduled Care 8am-10pm Secondary care GP (Spoke) 8am-8pm GP (Spoke) 8am-8pm GP Front End (Hub) 8am-8pm- commission GP Front End (Hub) 8am-8pm- commission Chronic Disease Management MDT working Outreach to home GP Federation Admin Hub Minor injury Diagnostics Ambulatory Care Link to GP OOH/111 Community and Social Care teams Rehabilitation Outreach to local population Rapid Response teams Link to community beds In-reach to hospital Community LTC Hub Specialist clinicians Advice and Guidance Cross-cutting services Diagnostics Elective Non- elective A&E Specialist services Link to GP OOH/111 Continuous focus on prevention Shared / interoperable records system (CIDR) Underpinned by: Underpinned by: Workforce development via partnership work across providers Camden Community Service (CCS) Key in year changes Integration with acute Commission GP front end front end hub Core GP service The Future circa 2017/18?