Workshop

Tuesday April 30th 2013

16:00 to 18:00

Mile End Education Centre

Integrated Care in Tower Hamlets

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Integrated Care-CHS Workshop

April 30th 2013

4.00 p.m. to 6.00 p.m.

Room 5a and 5b, Mile End Education Centre

This is a practical session providing an opportunity for primary care to flesh out the proposals

identified in the 18th April workshop and to assist in making the CHS changes effective.

The Specific Objectives of the Session are to:

Shape how we wish the system to operate in September 2013

Provide feedback into the stakeholder event on 23 May

Programme for the Session

Timing Session

4:00 Introduction to the session Progress made on Integrated Care in terms of the end vision Agreed positions so far on the principles and the operation of core

processes Purpose of this session given this context

4:30 Break out session focusing on the 5 areas explore what processes are required between primary care and CHS to support the changes:

Care Co-ordination Referrals and hubs The operation of multi-disciplinary teams The relationship between primary care and CHS Consent and information exchange

5:10 Review the issues and establish what we are expecting from CHS

5:50 Agree follow-up

6:00 Finish

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An integrated care system in Tower Hamlets will improve patient outcomes and ensure quality care at the minimum necessary cost

Empower patients, users and their carers

▪ Enable patients and service users to live independently and remain socially active

▪ Establish education and self-care programmes for patients

▪ Personalise care to patients’ and service users’ needs and preferences

Provide more responsive, coordinated and proactive care

▪ Proactively manage patient’s health towards their own goals of care

▪ Enable high-quality care that responds to patient/service user needs rapidly in crisis situations

▪ Provide more care in the community or at home

▪ Prevent avoidable admissions

▪ Leverage tools and technology to deliver timely and better quality of care

Ensure consistency and efficiency of care

▪ Deliver the best possible care at minimum necessary costs

▪ Avoid duplication of effort in situations where patient is seen by multiple health and social care providers

▪ Ensure most effective possible use of clinical time and resources

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This integrated care system will deliver nine key interventions

Care coordi-nation

Ensuring patient is in the most appro-priate setting of care

Self-care

Health and social care navigation

▪ Administrative support to ensure patient is following the care plan, that care required for a patient takes place and that a patient is able to secure any appointments required and is actually attending them when needed, across both health and social care

Case management ▪ Deliver care and perform detailed review of a patient’s case and condition by GPs, case manager, or MDTs either in person or remotely to determine any treatments or actions required

Care planning

▪ Conduct joint health and social care assessment of patient needs and jointly create a care plan with patient for care needed , to include goals, required interventions, provider details, and information on who to reach out to in case of need. This should also trigger a request for specific services e.g. falls assessment

Specialist input in the community

▪ Ensure specialists are able to provide support in the community for GPs or to provide input for patients

Self care, behaviour, and expectation management

▪ Empower patients to manage their own condition through provision of tools, education and guidance on behaviours. Clarify expectations in terms of what different services can provide in terms of care

Discharge support from acute to community

▪ Ensure discharge planning starts from day 1, that patients are assessed regularly during their stay, and that all required care packages are in place for when the patient returns home. This will also aim to ensure that post-acute care can happen at home as much as possible, e.g. rehabilitation, or within alternative housing options and that it can be put in place in time for a patient’s discharge

Mental health liaison ▪ Ensure that patients presenting in A&E and on acute wards are adequately diagnosed for

MH comorbidities and referred to the right setting of care. These patients typically include conditions such as alcohol, substance misuse and dementia

Rapid response with short term reablement

▪ Provide an alternative to unnecessary acute and care home admissions by responding to patient’s need in situations of crisis and ensuring that the relevant providers are able to put in care packages quickly to support the patient at home

Discharge support for MH patients from secondary to primary care

▪ Ensure that patients who no longer require specialist MH care are transitioned to primary care and that GPs are empowered to care for them

Joint health, social care, and mental health ap-proach

Improving access to primary care and to various services is critical to ensuring the success of these interventions

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TH integrated care work streams

Frail and elderly NIS

risk stratification

WELC integrated care changes

Discharge planning, rapid response and reablement, care coordination

CHS changes in locality community health teams

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Current State

Adult Community Nursing; – providing nursing care in the community both with a case mix of health maintenance; management of long term conditions; supporting discharge from hospital; some prevention of admission to 2nd care; managing short term episodes of care; supporting EoL care.

Community Virtual ward – providing management of long term conditions for those identified as high risk (PaRR >70) of admission to hospital by actively managing and supporting self care in this group of individuals. (this group also supported by case managers)

CReST – providing short term intervention to either prevent admission or support discharge home; managing short term episodes of care; i.e. IV therapy; intermediate care & rehab.

Specialist nurses – range of disciplines providing advice and support to patients and other health professionals;

Palliative care centre – provides advice and support to individuals and health professionals

Referral Hub - Acts as a single point of access for some of our services; not but not all

CHS currently has several adult services working with similar or same patient groups. These include

These services work as independent services and do not necessarily have established pathways between them or co-ordinated approaches to care. All interface with the same agencies to varying degrees, leading to some level duplication

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Integrated service

Create Senior Nurse/AHP led Community Health Teams - managing a step up/down approach to care from 2 hour response for more urgent interventions through to self care

Clinical support to/from GP and Community Geriatrician

Create one community services in-reach process

One point of access (referral hub) for CHS Community Health Teams

Develop IT systems that can act as single care record, provide community information dataset and share patient information along the pathway

With commissioners and partners develop further integrated care with mental health/social care into Community Health Teams

With commissioners develop outcome based KPIs

Specialist nursing/therapies support Community Health Teams deliver care along the step up/down continuum e.g. Respiratory care services.

Create one referral hub for all CHS services that manages referrals in and co-ordinates service responses & acts a single point of access.

This would require transformation & merging of A&C to support new teams, roles & functions

Specialist Support Team/s

Future State

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Benefits

• Single point of access to CHS services.

• Single team co-ordinating management of patient care through the continuum

• More efficient use of clinical resources

• Efficiencies delivered through team integration rather than differing service lines

• Greater focus on Multi-disciplinary team approach to care

• Greater focus on promoting self care

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Our integrated care system will wrap integrated care coordination and care provision teams around patients and primary care, at the appropriate scale

Patient

▪ Supported by integrated system to self-care

Practice ▪ Accountable for care coordination of top 20% at risk

registered patients ▪ Care coordination includes assessments, care plans,

reviews , and navigation (supported by case managers and care navigators from the network or ICHT)

Network

▪ Management, administrative and clinical resource to support practices in care coordination for patients

▪ MDT case conferences at network level to discuss complex patients, bringing together the full team around the patient (primary, community, secondary, social, mental health)

Locality (Integrated Community Health Team)

▪ Integrated (ideally co-located) teams of physical, mental, social care providers wrapped around networks (one team to two networks)

Borough

▪ Specialist/expert input to local teams (e.g. through attendance at network-level case conferences)

Patient

Practice nurse

HCA

Practice

Network

Locality

Borough

GP

Network manager

Network coordi-nator

Care navigators (HR/MR patients)1

Case man-agers (VHR patients)1

Social workers

AHPs

Hybrid health/ social support workers

Acute specialist

Primarily care coordination Primarily care provision

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Purpose of this session

• Very practical

• Focus on integration of primary care with CHS services

– Enabling integration for September 2013

– Enabling later phases of integration with social care

– Initial focus on patients most at risk of needing hospital services

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Initial key areas for small group working this afternoon

• Care Co-ordination

• Referrals and hubs

• The operation of multi-disciplinary teams

• The relationship between primary care and CHS

• Consent and information exchange

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Care Coordination

• How should we be working with patients, families and carers to assess needs and to plan care/enablement of self management ?

• What is our expectation of the process of coordination ( what is it )?

• Who fulfils the coordination role and from which organisation ?

• How do we know at any one time, who has what responsibility for care and support ?

• How will services be scheduled and who needs to know, and how?

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The relationship between primary care and CHS

• What kind of relationship do we want?

• What kind of measures do we want to use to assess good care ( at individual patient level and organisationally)?

• What might a charter look like between Primary Care and CHS ?

• What will make for the closest and most productive relationship?

– Sharing of information

– Recognition of performance

– Joint learning and review

– Location of services

• What would make this practical at the network and the Locality levels?

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How the multi-disciplinary team should function

• How to ensure a real team approach?

• How GPs and other practice staff can access CHS staff and services away from meetings-informal methods of communication ?

• How should we do case reviews ( face to face, virtual,)?

• What would make case conferences most effective (attendance, process, follow-up)?

• What do we need to get right in terms of style and language of meetings ?

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The organisation of CHS services- the hubs

• Which services should be organised on a network basis?

• Which services should be organised on a locality basis?

• How do practice staff communicate with the services?

• How are referrals managed?

• How are hand offs between professionals managed?

• How does the organisation of services need to change out of hours?

• What is the role of THEDOC?

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Information sharing and consent

• What information needs to be shared between Primary Care and CHS at different points of the process?

– At assessment and care planning

– At scheduling of services

– At delivery

– At evaluation and review

• How do we ensure critical information is shared with CHS in September?

• How do might we help CHS connect with EMIS ?

• What information should reside with the patient and their families and what would be a practical way of documenting/housing the information ?

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