Download - Integrated Care Programme (ICP) Locality Hubs Model of Care for Frailty 30 th January 2014
Integrated Care Programme (ICP)Locality HubsModel of Care for Frailty
30th January 2014
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Context – Integrated Care Programme & Locality Hubs
• ICP forms part of CCG’s Strategic Commissioning Plan
• A major component is the design of a new Locality Hubs model of care for frailty
• Full service launch planned for April 2016
• Fully commissioned service launched by April 2017
• First phase in Woking
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Context - drivers for change
• Ageing population, people living longer & more people living with chronic conditions
• Cost & demand pressures
• Overreliance on hospitals & residential care
• Not enough focus on prevention & early intervention
• Disconnect between social & medicalised care
• Fragmented delivery of services leading to duplication & a lack of coordination
• GPs as mainstay of the local care system – wider Primary Care, delivered at scale
Fully aligned with recommendations in the 5 Year Forward Review
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We started with a hypothesis…
~30% of people in an acute bed at any one time never needed an acute admission
~30% of people in an acute bed are receiving no active care & are waiting to be discharged
We have most (if not all) of the services we need to provide best possible care for
our population
So what do we need to do differently?
~30% of people have challenges that are social and rooted in isolation rather than medical needs
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We need to…
• Create greater confidence & capability to keep people safe and well at home, and in the community, without the need for acute admission…
• …by introducing primary care physician leadership into the out of hospital environment for medical care…
• …to better integrate services around our patients….
• …and take a more proactive approach to the care delivery.
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Our hypothesis led us to two key ambitions
1) No one should be in an acute bed because
they are frail&
2) No one should become frail if they can be helped to stay well
Better outcomes & quality of life
Less pressure on the acute
sector
Improved care quality & patient
experience
More cost-effective and
better value care
Optimised health & social care resources
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We’ve created 3 ‘frailty domains’ based on people’s needs
Frailty domains
Mobility & Daily Living
Cognition & Mood
Physical wellbeing
• Mobility and stability• Nutrition and hydration• Continence
Examples of need
• Dementia and rationality• Depression and anxiety
• CV disease with– Diabetes– A. Fib. / CVD– PVD
• Respiratory Disease• Neurological Disorders
• There are many definitions of frailty (E.g. Edmonton scale) and all capture elements of physical, mental and general wellbeing
• The system support needed to help a given patient will depend on the degree of need, the individual’s ability to cope with their circumstances and the degree of family / friend support available
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We’ve quantified the target patient cohort by segment
Adaptive Assisted DependentIndependent EOLC
ManagedTransition
ManagedTransition
ManagedTransition
ManagedTransition
Hub scope
Criteria used to estimate target population by segment
• >75 & identified by GPs as Frail using Edmonton Scale• Identified as at risk from functional decline & avoidable admission e.g.
• Advanced lung function and breathing problems• Progressive neurological problems, including Dementia• In-dwelling catheters• Advanced cardiac disease
• Includes:• Nursing & residential home residents• EoL
~5k ~4.7k ~5.3k = ~15k
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Frailty domains cut across segments creating a ‘matrix of need’
Adaptive Assisted DependentIndependent EOLC
ManagedTransition
ManagedTransition
ManagedTransition
ManagedTransition
Frailty domains
Mobility & Daily Living
Cognition & Mood
Physical wellbeing
Hub scope
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These needs will be addressed by 7 service lines spanning each domain & segment which together form part of a person’s care plan
Independent EOLC
Frailty domains
Adaptive Assisted Dependent
Adherence & PersistenceAdherence & Persistence
Adaptive Environment & Assistive Tech.Adaptive Environment & Assistive Tech.
Medical Monitoring & TestingMedical Monitoring & Testing
Medication ManagementMedication Management
Emotional ResilienceEmotional Resilience
TransitionsTransitions
Each element to be addressed as part of care plan
w
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uv
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x
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Mobility & Daily Living
Cognition & Mood
Physical wellbeing
Locality Hub
Carers, Family, Friends & Community SupportCarers, Family, Friends & Community Support
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“I do the things that keep me well and I will do them for the long term”
• Patient: nutrition, hydration, alcohol and smoking, hygiene, catheter care, coaching, shared decision support, patient rehab, manual handling advice
• Carer: care plan understanding, available support learning, best practice learning
• Staff: technical training, shared decision making, motivational interviewing
Coaching, training & education
• Exercise classes (mental / physical; regular / trial)
• Meals (at the Locality Hub)Well-being
classes
Adherence & PersistenceAdherence & Persistenceu
INTERVENTION EXAMPLE ACTIVITIES
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“I get the tools I need to keep me mobile, enable me to function day to day & manage my own health”
• Remote monitoring & access (BP, warfarin, lung function, safety, CPAP, telecare, BAS, suction, movement pattern, e-prescribing, e-carte
• Reminder aids (text, email, phone call), pill dispensers• Sensory aids (e.g. hearing aid)
ElectronicDevices
• Walking aids, splints and supports, assistive devices for ADL, other aids
Mobility Aids
Adaptive Environment & Assistive TechnologyAdaptive Environment & Assistive Technologyv
• Home assessments
• Advice on home environment – safety checks
• Bathing equipment, lifts, hoists, ramps etc.
• Meal preparation support
HomeAdaptions
INTERVENTION EXAMPLE ACTIVITIES
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“I have the regular check-ups I need to stay well & get treatment quickly when I need it”
• GP led check-up• Nurse led check-up (Practice Nurse/Healthcare Assistant)• Pharmacist led check-up
RegularCheck-ups
• CV, Respiratory, Neurological disorders, Geriatrician, Psychiatry, Podiatry, other
SpecialistConsultation
Medical Monitoring & TestingMedical Monitoring & Testing
• Blood pressure & hypertension• Hearing• Gait• Visual Acuity• Memory
Diagnostics & Screening
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Minor Elective Procedures
• Continence• Skin Assessment• Bloods & Urine tests• Bladder screening• Spirometry
• Catheter replacement• Stoma Care• Infusion treatment• Sigmoidoscopy
• Endoscopy/Colonoscopy• Fluoroscopy• Pressure sore care• Epidural steroids• IV Care
INTERVENTION EXAMPLE ACTIVITIES
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“I’m on the medications that best suit me, I know how to use them properly & I’m reviewed regularly”
• Review of drug portfolio, drug-disease interaction, side effect and A/I barrier
MedicationReview
• Pharmacist supported chronic medication dispensing and intravenous treatmentDispensing
Medication ManagementMedication Managementx
INTERVENTION EXAMPLE ACTIVITIES
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“I make best use of the resources around me & my carers are supported to help me”
• Local community centres and faith groups• Voluntary opportunities• Support to use Surrey Information Point• Neighbourhood schemes• Food banks etc.
Information & signposting
• Carers assessment and adviceAssessment for carer support
Carers, Family, Friends & Community SupportCarers, Family, Friends & Community Support
• Signpost to local carer groups and services• Registering with carers emergency respite services • Practical care advice and training• Dementia café
Carer support & training
y
INTERVENTION EXAMPLE ACTIVITIES
“I feel supported in my caring role and get support to have a life outside caring”
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“I feel happy & able to cope with my circumstances & I know where to get help when I need it”
• Named care coordinator• Telephone outreach• Befriending• Personal coaching – activation• Counselling
Individual Support
• Meeting at the hub• Good neighbour schemes• Use of community centres
GroupSupport
Emotional ResilienceEmotional Resiliencez
INTERVENTION EXAMPLE ACTIVITIES
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“I know what to do when things change, & the people that know me & my circumstances are there to support me”
• Single point of contact
• Immediate management of acute episode / exacerbationCrisis
Management
• 2 hour response service• Same day response service• Wound management• Outpatient specialist consultation for new condition
Rapid Response
Transitions Transitions {
• Proactive in-reach into A&E and hospital to pull people through the urgent care system
• Rehabilitation
Discharge to Assess
INTERVENTION EXAMPLE ACTIVITIES
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Hospital
Locality Hub – conceptual model (one-stop-shop)
Tra
ns
po
rt
X
Place of residencee.g. • Home• Nursing Home• Residential Home• Extra Care Housing
Hub out-reach
Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector
Self Care
Care packages
Hub out-reach into hospital to proactively pull people through the urgent care system
Diagnostics
Pharmacy
Support services
A physical building next to a community hospital providing an integrated frailty service for people & their carers with all locality GP practices and services operating in a network
Locality Hub
People are referred to the Hub from local services based on flags for high risk & formal screening at GP surgeries
Assessment, Care Coordination & Care Planning
Adherence & PersistenceAdherence & Persistence
Adaptive Environment & Assistive Tech.Adaptive Environment & Assistive Tech.
Medical Monitoring & TestingMedical Monitoring & Testing
Medication ManagementMedication Management
Emotional ResilienceEmotional Resilience
TransitionsTransitions
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uv
z
x
{
Carers, Family, Friends & Community SupportCarers, Family, Friends & Community Support
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Indicative high-level roadmap
14/15 15/16 16/17 17/18March March March
DevelopServiceSpecification
Run ProcurementAll Localities
(Service fully commissioned)
WokingPilot Live
Thames Medical
SASSE
Woking
3 Locality Hubs(fully operational)
Implementation Plan in development