s109 – day 1 – 1315 – achieving patient orchestrated care

Patient Orchestrated

Care

Bridget Fletcher, Chief Executive

Dr Richard Pope, Hon Consultant Physician

overwhelming

need for

change

“Trabant Care”

“…I am scared to say something in case there are consequences…”

Through their eyes…

“…I know you are busy but I am important too…” “…Make me feel I matter…”

“…I am not a disease – I am a person…” “…This may be routine for you – but for me it

is the first time…”

“…I may be old – but I have a brain…”

“…Different professionals are telling me different things – who is right?...”

“

“Apple

Care”

Incremental vs Disruptive

Innovation

“Our NHS does a superb job

for millions of people, day in, day out,

but it cannot stand still

– it needs to adapt to survive” Sir Bruce Keogh

Traditionally….

Potentially…..

How can a person

orchestrate their own care?

Teleconsultation - Airedale

8 year journey

Initially prison healthcare

Today work with prisons

across England

~ 800 cases/year

Wide range of specialties

Have extended services……

Current applications

Telehealth Hub 24/7 working

Experienced nurses

2nd tier - physician

Range of technologies

Shared EHR

Resilient infrastructure

Opened September 2011

Nursing

& Residential

Care homes

n=96 live today

deploying to 190

Cumbria to Kent

Care home

caseload audit (Feb 2014) Current care homes

Mix of Residential /

Nursing

Total 2500 residents

Aged 26-106

Looking only at those

homes that refer into

Airedale hospital ….

Call outcomes

Care Homes - summary

0

100

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400

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700Acute Admissions 1Year Prior toDeployment ofTelemedicine

Acute Admissions 1Year PostDeployment ofTelemedicine

-35%

Care Homes continued

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800

1000A&E Attendances 1Year Prior toDeployment ofTelemedicine

A&E Attendances 1Year PostDeployment ofTelemedicine

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6000

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10000Acute Beds Days 1Year Prior toDeployment ofTelemedicine

Acute Beds Days 1Year Post toDeployment ofTelemedicine

-53%

-59%

Results: 24 hr teleconsults to 26 COPD patients

at home – 1 year pre/post

-45%

ED attends

-60%

Feedback…

“I would like to express my

gratitude and thanks for the level of care you have

provided my husband, in particular the consultation at the weekend – the service is

marvellous.”

“The Doctor was fantastic when one of our dementia patients fell and hurt

herself. I would have called an ambulance and she would have endured an A&E visit which would have terrified

her. Your consultant saved her from this and reassured me that the cut was

superficial and she was fine…”

“A very good service. It made me confident within my job so I could do the best I can for our

residents. This service taken the pressure off us as we have

access quickly to a health professional.”

“I have only one word to describe Telehealth –

excellent.”

“ The Telehealth Hub came into its own last winter when snow and ice brought traffic to a halt. My Husband’s condition deteriorated suddenly and having visual, instant contact with the team was very

reassuring. A wonderful service.

People want to “live” with their LTCs

The NHS needs increased Quality

and Improved Efficiency These seemingly conflicting demands can be resolved by

A different Patient Clinician

Engagement making it personal, not simply clinical

Scale - to thousands of HCPs, millions of Patients

People with LTCs - owning their plans and

defining their support

First tried it ‘on paper’ – cohort of 50 carefully tracked

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Practice visits

Pre-care planning

Post care planning

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Outpatient attendances

Pre-care planning

Post care planning

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A&E attendances

Pre-care planning

Post care planning

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Patient code

Acute admissions

Pre-care planning

Post care planning

Published in HSJ Dec 2010: “QIPP and Care Plans for long term conditions”

© Dynamic Health Systems

Example - engaging with own action plan

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Exercise sessions per week

Starts using SSC here Patient generated data

Patient generated data

Feeling better – motivated by results

73.00

74.00

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80.00

81.00

82.00

12/23/11 0:00 2/11/12 0:00 4/1/12 0:00 5/21/12 0:00 7/10/12 0:00 8/29/12 0:00 10/18/12 0:00 12/7/12 0:00 1/26/13 0:00 3/17/13 0:00 5/6/13 0:00

Weight (kg)

Starts using SSC here Patient generated data

Clinician generated data

Achievement confirmed by clinical results

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1/22/10 0:00 8/10/10 0:00 2/26/11 0:00 9/14/11 0:00 4/1/12 0:00 10/18/12 0:00 5/6/13 0:00

Haemoglobin A1c level - IFCC standardised

Starts using SSC here

QoF

Clinician generated data

In control – aged 80 and happy!

In control,

80 & happy

Initial Cohort - age profile

yrs

Patient No.

BP before and after 6 months use of supported self care

BP before and after 6 months use of supported self care

Patient No.

mm Hg

Ave reduction SBP=19mm DBP=13mm

HbA1c change over 6 months following introduction of

supported self care

Ave = -16 mMol/ Mol

Weight change (Kg) over 6 months following the

introduction of supported self care

Ave loss = 4.5Kg

The person orchestrating their own care with clinicians working by exception

Technologies

converge….

signalling

choice

& needs

near the

end of life