‘Integrated Care Teams’QIPP Long Term Conditions

Dr J JohnNational Clinical Associate in LTC/QIPP

Department of Health

19th July 2012Kent and Medway LTC Programme

Statistics Long term conditions represent… The average

annual health cost…

170,000 people die prematurely of

long-term conditions each

year

Significant variation across PCTs exists in

emergency hospital use

60%

The Case for Change

252%

rise just in Diabetes by 2050188%

increase in the number of patients with multiple LTCs by 2013

rise in over 65 year olds by 2050

Current Spend2011

Projected Spend 2016

Pay: 3+ Long Term Conditions Date:

2011Amount in Words: Nineteen Billion Pounds

Signed:

__________

£19,000,000,000

Pay: 3+ Long Term Conditions Date:

2016Amount in Words: Twenty Six Billion Pounds

Signed:

___________

£26,000,000,000

The Case for Change

No health care system is sustainable in the face of this tsunami of need

The systems perspective

The patient perspective

QIPP LTC WorkstreamP

rim

ary

dri

vers

: Risk Profiling

Integrated care teams at locality level

Systematic empowerment of patients to self manage

Integrated teams

• Improved health status, reduced weight and improved diet1,4

• People were most likely to be alive, living independently at home6

• Improved symptoms and behaviours5

• Improved health status & mental well-being. Outcomes for lower cost3,7

Source: (1) Kasper “A Randomized Trial of the Efficacy of Multidisciplinary Care in Heart Failure Outpatients at High Risk of Hospital Readmission”. Journal of the American College of Cardiology Vol. 39, No. 3, 2002

Source: (2) Griffiths. “Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme”. Thorax 2001;56:779–784

Source: (3) van den Hout “Patient team care nurse specialist care, inpatient team care, and day arthritis: a randomised comparison of clinical multidisciplinary care in patients with rheumatoid”. Ann Rheum Dis 2003 62: 308-315

Source: (4) Capomolla et al. “Cost/utility ratio in chronic heart failure: comparison between heart failure management programme delivered by day-hospital and usual care” J Am Coll Cardiol 2002; 40: 1259-66

Source: (5) Opie, Doyle & O’Connor “Challenging behaviours in nursing home residents with dementia: a RCT of multidisciplinary interventions” Int J Geriatr Psychiatry 2002; 17(1):6-13

Source: (6) Stroke Unit Trialists’ collaboration “Organised inpatient care for stroke” Cochrane Library, issue 2, 2004

Source: (7) Ahlmen et al “Team vrs non-team outpatient care in rheumatoid arthritis” Arthritis Rheum 1988; 31(4): 471-9

The Vision in ONEL

Population Size: 236,000Population Size:

180,000

Population Size: 270,000

Population Size: 227,000

41 GP Practices

54 GP Practices

45 GP Practices

47 GP Practices

Coordinated care for patients and carers in the community

Optimal patient experience and clinical outcomes

Lower cost, better productivity

Whole system change (1,000,000 patients)

Outline / Aims of the Project

• Providing Integrated Care services where “the patient receives the care that they want and nothing more; the care that they need and nothing less”.

• Partnership working between the GP practice, Social services and provider services.

• Avoids duplication of services.

 

Aims:Integrated Teams

Aims: Integrated Teams

• Provides proactive management of long term conditions and social needs.  

• Prevents avoidable hospital admissions because of robust planned care and patient education

• Reduction in permanent admissions to residential and nursing homes

Component Parts of ICM

ONEL :Integrated Care Team

Therapies

Acute care

specialists

End of Life

Mental health

Voluntary Sector

Drug & Alcohol services

*Named District Nursing Sister and allocated Band 5 Community Nurse

GP PRACTICE x7

COMMUNITY MATRON

COORDINATOR

SOCIAL WORKERS

OT

DISTRICT NURSES*

LD SUPPORT(virtual)

MH SUPPORT(virtual)

GP PRACTICE x7

COMMUNITY MATRON

COORDINATOR

SOCIAL WORKERS

OT

DISTRICT NURSES*

LD SUPPORT(virtual)

MH SUPPORT(virtual)

CLUSTER 1 CLUSTER 2 CLUSTER 3 CLUSTER 4 CLUSTER 5 CLUSTER 6

The Model:Co located

Community Planned Care

(health & social care)

Access

Integrated Case Management Overview

Identify Service User

High Risk patients identified via Health Analytics and Clinical Expertise

The Integrated Care Team

- GP- Community Matron- Social Worker- District Nurse- Integrated Case Coordinator- Additional Specialist / Voluntary Sector as needed.

Case Conference & Care Plan

Fortnightly meetings at practice level High risk patients discussed and care plan Implemented

Care Delivery

Care delivery by Integrated Team as coordinated by Integrated Care Coordinator with the patient

Ongoing Care

Onward Referral

Self Management

Care Plan Review

Single point of access

Provides 24/7 Nursing / Reablement to prevent hospital admissions and support early discharge

Works in partnership with Out of Hours GP services to prevent hospital admission

Works in partnership with the London Ambulance Services in full to prevent hospital admission

Admits Patients to step up community beds to provide short term interventional care

Rapid response underpins the integrated care model and provides nursing /reablement unplanned care 24/7 up to 14 days to prevent hospital admissions and promote early

supported discharge

Community unplanned care (health & social care)

Rapid Response

Experience based design videos to co-own/produce new ways working

Workstreams- coproductionVisits undertaken to more than 140

GP practices in ONELStakeholder engagement events

organised for each boroughMeetings with each stakeholder –

social services, community provider, acute trust, Public health, Voluntary

ONEL strategy sessionsFeedback from patients / pilot sites

at B&D

Outline case presented to each stakeholder

Research activity to identify best practice

Significant time spent by the QIPP team in shaping the model of care.

DH support/Visits to other sites for learning

Business cases, Practice support,Estates

Governance agreements/documentsModelling activity to determine

savings

Stakeholder engagement Planning/ Implementation

Planning and Implementation

Case Study 1

Patient BM

80 year old F in top

1% who needed

more intervention

as time progressed

MHX: AF, CCF,

Hypertension, PVD,

COPD under 4

specialist teams

(London and local)

Social: Lives alone,

help from niece,

carers going in twice

a day

Pre IC:

No feed back from disciplines frequent hospital admissions no team approach to patient poor outcomes depression

Post IC:

More joined up working More effective use of services in the community Patient feels more supported Trying to address key issues (pain) and more accountable ownership of particular patient problems via specialist teams in the community

Overall Outcomes

Quality Outcomes Over 1300 patients with MDT care plans in place

132 GP practices, 3 local authorities, 2 acute trusts and 1 community provider

delivering the model of care ( Integrated Care Coalition)

Improved co-ordinated care by multi-disciplinary teams and reduced duplication

Every patient has a nominated and dedicated coordinator to coordinate personalised

care

Rapid access to social care as needed through direct referral to social care

Social Care Improvements

• Reclaiming social work• Shared risk taking• Improved referral pathway• Locality working – personalisation spin offs• Hospital in-reach• Reduction in admissions to residential care• Significant increase in SDS performance

Overall Outcomes

Financial Outcomes

Reduction in length of stay for patients with LTC in comparison to 10/11. 12%

reduction in Waltham Forest and a 9% reduction in Redbridge , 10% in B and D

Reduction in the number of referrals to nursing / residential homes

Increased timeliness of care packages

Reduction in the number of safeguarding referrals

Overall Outcomes

Operational Outcomes

Transformational community nursing workforce development

Co-location of health and social care teams in B&D and Redbridge building “high trust”

partnership teams

Establishment of strong collaborative working with primary/ community teams and secondary

care to support patients across the pathway

Full roll out of integrated data platform to integrated health intelligence from acute, GP, social

care and community data sources across all boroughs to target appropriate patients for

model of care

Improvement in staff retention in services

Now a site for – ‘Year of Care Pilot’ for the DH

Support

• Website, Update, Resources, Virtual programme, LTC Commissioning Pathway

• Local Support-

• National Coach (DH) and Queens Nurse- Sharon Lee

Future

The best way to predict the future is to create it

Peter Drucker