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Integrating Care for Frail and Elderly
The overall approach
High quality services
Identification
Good care in the right place at the right time
Health and social care built around people’s needs
…of people at high risk of illness or complications
- Clearly defined pathways- Sufficient capacity and skills- Quality of care information
measures & feedback
- Creating an environment that promotes collaboration between existing services
- Investing in services/roles that promote integrated care
- Contractually incentivising an integrated care approach
- Adequately resourced services responsible for identifying people at high risk
- Training - Maximum use of IT capability
Improved Outcomes
Prevention where possible - Early diagnosis - Consistent quality - Patient consultation - Review and reconfigure if necessary
Integrated Care
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Integrating Care for Frail and Elderly
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Component 1: MDT
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Component 2: LCS for Complex Care
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Component 3: Frailty Education
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Component 4: CIDR
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Component 5: Complex Care Nurses
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Component 6: Community Geriatricians
Platform - Camden Integrated Digital Record (CIDR)
Primary Care Community Care
Secondary Care
Risk Stratification
CCM LCS
Community Geriatricians
Case Management
Social Care in Primary Care
Care Navigation
Camden Integrated Care Service (CICS)
Education Module
High Quality Service
Integrated Care
Identification
Component 7: Social Care in Primary Care – and Care Navigators
Trends in the observed and expected emergency admissions (all) for those aged 75+ years resident in Camden LA, 2005 to 2013 (Source: Nuffield Trust).
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 50 100 150 200
Percentage of time spent at home - MDT patients
Time spent at home pre-MDT Time spent at home post-MDT
Spent more time at home after MDT (59%)
Saw no change (11%) Spent more time at
home before MDT (30%)
13
Financial impact of the MDTThe savings below represent activity removed from acute hospitals in A&E and emergency admissions, in the 12 months following the patient’s first MDT review (or up to the date a patient is no longer registered in the borough, or is deceased).
A&E average monthly saving 2014 is £2,606
Emergency admissions average monthly saving 2014 is £32,988
-£10,000
-£8,000
-£6,000
-£4,000
-£2,000
£0
£2,000
£4,000
£6,000
£8,000
£10,000
£12,000
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
2012 2013 2014
MDT related A&E savings per monthRow Labels Sum of 12 month QIPP savings
2012Aug -£7,224Sep £3,818Oct £1,993Nov £3,089Dec -£981
2013Jan £3,326Feb £6,387Mar £899Apr -£862May -£94Jun -£1,563Jul £3,046Aug £1,546Sep £4,105Oct £2,539Nov £577Dec £1,524
2014Jan £1,832Feb £2,511Mar £4,069Apr £9,262May £4,496Jun £3,524Jul £1,529Aug -£1,031Sep -£492Oct £358
Grand Total £48,182
Row Labels Sum of 12 month QIPP savings2012
Aug -£125,808Sep £34,405Oct £51,920Nov £76,287Dec -£28,907
2013Jan £90,544Feb £71,174Mar £25,853Apr £12,996May £22,115Jun -£84,088Jul £9,168Aug £34,802Sep £70,564Oct £91,821Nov £40,726Dec -£32,195
2014Jan £50,102Feb £23,351Mar £17,183Apr £134,041May £16,222Jun £52,668Jul £64,978Aug -£9,914Sep -£54,107Oct £35,358
Grand Total £691,258
-£150,000
-£100,000
-£50,000
£0
£50,000
£100,000
£150,000
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
2012 2013 2014
MDT related emergency admissions savings per month
Next steps – Formalised Frailty Service Model
Level of need: severely frailCare setting: acute/community/home
Level of need:moderately frailCare setting: primary care/community/home
Level of need:mildly frailCare setting: primary care/community/home
Level of need: pre-frailCare setting: primary care/home
4
3
2
1
Next steps – Formalised Frailty Service Model
Primary Care
Community Care
Hospital Care
