INTEGRATING CARE ACROSS MID NOTTINGHAMSHIRE

Transforming Care for People with Long Term Conditions and the Frail Elderly

July 2013

Across Mid Nottinghamshire• The total cost of the physical health and social care economy is £398m.• The 19m funding gap from 2012-13 could increase to at least £70m, and possibly

be more than £100m by 2018.

2

Toda

y Y1

Y2

Y3

Y4

Y5

Y6

Y7

Y8

Y9

Y10

Y11

Y12

0

100

200

300

400

500

600

Total funding: Health & social care Total cost

Mill

ions

of p

ound

s (£

)

Current Financial gap = £19m 5 Year Financial gap = £70m 10 year Financial gap = £140m

Our financial challenge

Qua

lity

of li

feWe have a vision for the next five years

£1 £10 £100 £1,000

ICU

ACUTE CARE

0%

COMMUNITY CARE

Self-management

Long Term Condition Management incl Cancer

Third sector provision

Primary Care

100%

Consultant-led services

Specialist teamsSpecialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

£5,000

Cost of Care per Day

Risk profiling

Patients and healthcare professionals told us that services were….

• Disease specific – patients often under the care of 3 or more different teams / individuals

• Fragmented, with poor communication between teams• Isolated – Silo services with health and social care working in isolation• Confusing – HCPs and patients don’t always know what services are

available and how to refer to them• Frustrating, with lengthy referral times / waits• Inconsistent, with patients falling through the gaps• Limited, particularly in relation to a lack of out of hours cover – only option

for some is 999• Overloaded, especially primary care and community services• Reactive – care is based around crisis management

Our Vision

To work collaboratively with our partners across the health economy to:

Transform the way we deliver care by creating a whole system, fully integrated hospital, community, primary and social care model.

Improve outcomes for patients with Long Term Conditions and the frail elderly.

Create access to better, more integrated care outside of hospital Reduce unnecessary hospital admissions Enable more effective working of healthcare professionals across

provider boundaries. Address the significant economic challenges ahead

Our Partners

Sherwood Forest Hospitals Foundation Trust Health Partnerships ( Community and Mental Health

Services Provider) Nottinghamshire County Council Newark and Sherwood District Council Newark and Sherwood CVS Self Help Nottingham Patients Carers

Integrating the management of cancer as a long term condition

This is Albert

76 years old Ex Miner Heart Failure Diabetes Hypertension History of alcohol abuse He is married to Mary who is 74. She has osteoporosis,

diabetes and arthritis. They live in a 3 bed ex council house in a rural area with a dog called Fred and have lost touch with most of their friends. They have 3 children who all live away.

Principles of the New Approach Radical – Completely redesign the system across the entire health economy. Work in partnership with all partners organisations A focus on proactive care to anticipate and prevent crisis Primary Care at the heart of the system – A community based model Systematic profiling and risk stratification of the whole population and

systematic streaming into dedicated services. Integration of care across the health and social care economy Personalised care designed around the patients’ needs Care planning and shared decision making to become systematically

embedded into every day practice Increased access to services around the clock and out of hours Recognition of the need to invest and commitment to do so

Risk Stratification

Risk Stratification

Using risk profiling software – The Devon Tool available to all GPs in all practices.

Combined Predictive Model developed and utilised in Torbay ICP.

Demonstrated 86% accuracy in predicting future admission

Utilised in 2 ways Service Planning and commissioning Practice Level Patient Identification

Devon Tool for Systematic Risk Profiling to identify risk

Top 0.5% Community Matron / Virtual Ward as part of Multidisciplinary Team (Community Geriatrician, GP, Social Care, Therapists, Rehab, Domiciliary )

Care Planning and individual personalised care plan

Disease Specialist Input where required from specialist community teams ( COPD, Diabetes)

Telehealth and Tele Care

Psychological Support

Planned hospital admission , proactive in reach and facilitated discharge where needed

0.6-5%Intensive disease / case management by specialist teams as part of the MDT

Telehealth / Telecare

Community Specialist Services and clinics with MDT support

Care Planning and individual personalised care plan

Planned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS

6-20%Proactive Disease Management by General Practice supported by specialist community services and teams

Care Planning and individualised Care plan

Support to Self Manage

Education Programmes

Annual Review

Specialist Medication reviews

Anticipatory Care

Remote monitoring via tele health where appropriate

Patients step up and down as risk profile changes

21% - 100%Proactive Self Care Support and Management in Primary Care

Risk score recorded and reviewed annually

Active Case Finding

Disease Register

Accurate diagnosis

Information Prescriptions

Care Planning

Education relevant to patients needs

Disease prevention andHealth promotion

HIGH RISK / ComplexityLow RISK / ComplexitySmoking Cessation, Health Promotion and Self Care

Admissions Avoidance

Public Health

Population wide Prevention

Disease awareness campaigns

Social marketing

Education

Health promotion

Schools

Workforce Development, Training and Education

Co-ordinated Social Care

Mid Nottinghamshire Integrated Model of Care for Long Term Conditions

Special Patient Notes / 24/7 Access to specialist support

Care Coordinator / Named Lead

1

2

3

4

Level

Integrated Care

Locality Based Integrated Care Teams

3 x locality based Multi-disciplinary teams / Virtual Wards North ward launched Dec12, West Ward March 13, Newark

Ward April 13 Each team comprising: ( all WTE posts)

Community Matrons District Nurses Occupational Therapist Physiotherapist Mental Health Worker Social Worker ( directly commissioned from LA by the CCG) Healthcare Assistants Voluntary / Third Sector Workers – Part of the MDT Ward Coordinator/ Manager

Underpinned by ………..

Specialist case management teams ( Level 3) for COPD, Heart Failure and Diabetes.

Community based clinics ( CVD, COPD, Diabetes) with commissioned consultant specialist support

Community nursing teams and GP practice teams integrated and aligned with each of the 3 ward teams throughout

Care Homes integrated into the Virtual wards – people treated as if they were in their own home.

In the process of commissioning Community Geriatrician support Increased provision of Intermediate care beds ( Step up and Step

down) Procurement of new Crisis Response Service ( June)

GP

GP

GP

2Community

Matrons

Community Nurses

Occupational Therapist

Community Support Workers

Ward Co-Ordinator

Physiotherapist

Social Worker M

onthly Risk Stratification

NamedCommunity Geriatrician

Named Specialist Nurse COPD

HF Diabetes

Cancer

Dietetics

Tissue Viability

Continence

Crisis Response / Rapid Intervention Service

Voluntary Services

Community Specialist TeamsDiabetes/ COPD/

Heart Failure/ CancerLevel 3 Case

ManagementStep Up Step Down between level 3 and

level 4 ( Virtual ward)

Linked to

Extended Team Support across all localities

Virtual WardCore Team

Podiatry

EMAS/ CN

CS/ OO

Hs

Intermediate Care

Access

to & Su

pport fro

m

KeyGP Practices/ Primary Care

Locality specific Virtual Ward / MDTs x 3

Cross locality support teams working across all localities and specialist disease management teams

CCG wide services

Specialist Community Teams – disease specific. Level 3 case management

Newark and Sherwood Integrated Team Model- LOCALITY VIEW

Mental Health Professional

Healthcare Assistants

NamedCommunity Oncologist

Voluntary Services

There will be three localities , North, South and Newark.The number of Virtual wards per locality will be dictated by the population and size. In areas where there is more than 1 virtual ward some roles will be shared between wards.

Comm munity Pharmacy

Medicines Management

Falls Team

Devon Tool for Systematic Risk Profiling to identify risk

Top 0.5% Community Matron / Virtual Ward as part of Multidisciplinary Team (Community Geriatrician, GP, Social Care, Therapists, Rehab, Domiciliary )

Care Planning and individual personalised care plan

Disease Specialist Input where required from specialist community teams ( COPD, Diabetes)

Telehealth and Tele Care

Psychological Support

Planned hospital admission , proactive in reach and facilitated discharge where needed

0.6-5%Intensive disease / case management by specialist teams as part of the MDT

Telehealth / Telecare

Community Specialist Services and clinics with MDT support

Care Planning and individual personalised care plan

Planned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS

6-20%Proactive Disease Management by General Practice supported by specialist community services and teams

Care Planning and individualised Care plan

Support to Self Manage

Education Programmes

Annual Review

Specialist Medication reviews

Anticipatory Care

Remote monitoring via tele health where appropriate

Patients step up and down as risk profile changes

21% - 100%Proactive Self Care Support and Management in Primary Care

Risk score recorded and reviewed annually

Active Case Finding

Disease Register

Accurate diagnosis

Information Prescriptions

Care Planning

Education relevant to patients needs

Disease prevention andHealth promotion

HIGH RISK / ComplexityLow RISK / ComplexitySmoking Cessation, Health Promotion and Self Care

Admissions Avoidance

Public Health

Population wide Prevention

Disease awareness campaigns

Social marketing

Education

Health promotion

Schools

Workforce Development, Training and Education

Co-ordinated Social Care

Mid Nottinghamshire Integrated Model of Care for Long Term Conditions

Special Patient Notes / 24/7 Access to specialist support

Care Coordinator / Named Lead

1

2

3

4

Level

Systematisation of Self Care

Systemisation of Self Care and Care Planning

Support to increase patient involvement in their own care Education Confidence Access to relevant support networks

Consultative care planning – we will do “with” and not “to” “No decision about me without me” Not just about giving information Improving and enhancing provision of carer support, information and

education Inclusion of voluntary sector services to improve patient/carer support

Self Care is EVERYONES responsibility during EVERY patient contact

The evidence shows that it is the cumulative effect of each of these intervention and actions that makes a difference…..

We have to do them all

What Have We Achieved to Date?

24

KPI Monitoring for PRISM – 10% reduction in emergency admissions for COPD, Diabetes and Heart Failure

0

50

100

150

200

250

Rolling 12 Month Total for Emergency Admissions with a Primary Diagnosis of COPD, Heart Failure or Diabetes (Adms upto Aug 2013)

N&S North N&S West Newark and Trent

North Team Go Live

West Team Go Live

Newark Team Go Live

25

Newark & Sherwood Emergency Admissions per 1,000 patients by PracticeMay 13 to July 13

MID

DLET

ON

LODG

E PR

ACTI

CE

CLIP

STO

NE H

EALT

H CE

NTRE

MAJ

OR

OAK

MED

ICAL

PRA

CTIC

E

SOUT

HWEL

L MED

ICAL

CEN

TRE

FARN

SFIE

LD S

URGE

RY

BILS

THO

RPE

SURG

ERY

RAIN

WO

RTH

HEAL

TH C

ENTR

E

BLID

WO

RTH

SURG

ERY

HILL

VIE

W S

URGE

RY

COLL

INGH

AM M

EDIC

AL C

ENTR

E

BALD

ERTO

N PR

IMAR

Y CA

RE C

ENTR

E

LOM

BARD

MED

ICAL

CEN

TRE

HOUN

SFIE

LD S

URGE

RY

BARN

BY G

ATE

SURG

ERY

FOUN

TAIN

MED

ICAL

CEN

TRE

0

5

10

15

20

25

30

35

Emergency Admissions per 1,000 Patients - May13 - Jul13

May12 - Jul12 May13 - Jul13

N&S North LocalityN&S West LocalityNewark and Trent Locality

What Have We Learned? Stakeholder engagement is key and must not be underestimated – invest in the time

up front GP buy in critical – Financial support to get things going Organisational sign up and commitment at senior level across all stakeholders Needs to be CCG core business not a bolt on. Dedicated project management – Needs to be someone's day ( and night!) job

Investment in community services Historic underinvestment meant we started from a low baseline Staff training and skills development Cultural as much as clinical

IT, Data and IG challenges – Expertise and investment required from day 1 Integrated Care on its own will not achieve the desired outcome Whole system redesign is required to underpin the model including urgent care Recognition that the outcomes wont necessarily be achieved immediately

Transformation vs QIPP

Benefits

In our Pilot, our admissions were reduced by 19% Joint Visits – addressing medical and social issues The team are contactable !! Any problems can be resolved quicker,

issues/problems are addressed that may previously have not been highlighted

Patients like it!

PRISM isn't a service – It’s a way of life !!

What Next? Further development and training of the Integrated Care

Teams and the MDT approach Proactive in reach for facilitated discharge Emergency care pathways – working with OOHs providers to

develop pathways to avoid unnecessary conveyance Embarking on “Year of Care” training for all clinicians Implementation of new self care strategy Development and implementation of cancer pathways and

support Joining up the IT Scale up and roll out across mid Nottinghamshire as part of

major Transformation Programme

The New Integrated Urgent & Proactive Care Model for Mid Nottinghamshire

Helping to shape future health and social care in Mid NottinghamshireCOMMERCIAL IN CONFIDENCE

We have a moral imperative to make the system fit for purpose for the changing demands of the population – people want to see joined up services and a system that is less complicated to access, retaining universal access

Helping to shape future health and social care in Mid Nottinghamshire

What do we mean by integrated care ?

“Care, which imposes the patient’s perspective as the organising principle of service delivery and makes redundant old supply-driven models of care provision. Integrated care enables health and social care provision that is flexible, personalised, and seamless.”

COMMERCIAL IN CONFIDENCE

Helping to shape future health and social care in Mid NottinghamshireCOMMERCIAL IN CONFIDENCE

Integration – a means to an end, not an end in itself

• Integrated care must focus on those patients for whom current care provision is disjointed and fragmented

• Effective system leadership must exist• The interaction between generalist and specialist clinicians

must promote real clinical integration• There must be integrated information systems• Financial and non-financial incentives must be aligned

Helping to shape future health and social care in Mid NottinghamshireCOMMERCIAL IN CONFIDENCE

The consequences of being ambitious are less scary than not being ambitious enough….

December 2013

Principles underpinning the design of the proactive and urgent care system

35

• Significant interdependencies between proactive care and urgent care, hence the decision to develop a joint business case

• None of the interventions can be considered or developed in isolation • Services will be available 7 days a week and, where necessary, 24/7• Care will be provided in a persons home wherever possible; the design focuses on

reducing the need for admission to hospital/residential care, but, where this is required, seeks to expedite the return home as quickly as possible

• Design spans health and social care, with joint funding and joint commissioning where appropriate

• Utilises learning from elsewhere• The patient and the carer is at the centre of all design (Albert) • Provider “Blind”• Patients will receive / have access to the same care / services regardless of where

they are domiciled ( ie care home vs Own Home ) • Mental Health out of scope per se but all interventions designed with provision for

interface

Care Navigator

Self care

Self Care Hub

Proactive and Urgent care model

Acute care

Care in the patient’s home Crisis notification Care navigation Acute care

A&E/ MAU/ WARD

Sing

le F

ront

D

oor

Maintain independence

Healthy living & wellbeing

Acute Medical Emergency

PRISM plus

Specialist Intermediate Care Team

Discharge coordination

Proactive care

Crisis Response Team Back door

MDTsGP/OoHEMAS

Social Care

Determine necessary care package and

deploy services

Virtual wards / MDTs

Intermediate care in the home

Low level support

Enhanced support

Intensive support

Risk Stratification

Bedded Intermediate Care

Low level support

Enhanced support

Intensive support

A m

ore

resp

onsi

ve p

rimar

y ca

re s

ervi

ce

Communicating effectively with the public

Urgent Care

Proactive care

Key:

Self Care Away from the community

Towards community

SICT

December 2013

Self Care

37

• New Self Care Hub which will bring together all self-care activity and support across mid Nottinghamshire and act as a single point of access to relevant support for both healthcare professionals and patients.

• It will enable patients to access information and practical support and advice to better manage their long term condition, to be signposted to self-care options, to make positive life style changes and learn essential skills.

• The hub will be staffed by trained support workers overseen by a small management team with additional support provided by trained volunteers who will:

• Work as part of the Virtual Ward / Integrated Care teams to provide self-care support directly to patients in the community

• Work within the hub itself to provide telephone support, signposting, and information to patients and healthcare professionals.

• The hub will also be used as a venue for specific training and education programmes for both patients and HCPs and also be utilised by other organisations wishing to provide or host self-care or care planning training and education events

• Oversight and delivery of structured disease management education programmes

December 2013

Virtual Ward MDT

38

• Expansion of PRISM Virtual wards to 8 across Mid Notts• Proactive care to pts at high risk of admission (identified via Devon Tool)• Rehab and reablement care for patients post crisis or post discharge• Work closely / aligned with Specialist Intermediate Care Team

• Care planned and appropriate resources deployed within the team/s to meet the level of input / support required by individual patients dependent on their specific needs at any given point

• Access to “fixed” beds for patients who require higher levels of support• Step Up / Step Down• MCH / Fernwood/ Existing Beds• Care Homes

• Continual review to facilitate timely step down through the model • Interface with Mental Health Intermediate Care Services

December 2013

Care navigator

39

• Professional staff will phone when they have a patient with an urgent care need and they are looking for community alternatives to admission or to support a discharge from hospital or care home

• Calls will be answered by a clinician (nurse, paramedic, SW) with rigorous call handling standards

• The service will operate from 8.00 - 22.00 each day as it is unlikely that effective navigation would be possible in the overnight period

• A Directory of Services will support the service; this will include a capacity indicator for services as well as their criteria for access, etc

• Calls can be patched through to secondary care consultant staff for clinical discussions on the management of a patient

• A GP will also be available for clinical discussion • By the end of the call the service will have agreed with the caller the package of

care to be delivered and the timeframe within which it must be in place• Admin team will make necessary referrals with safety net procedure sin place to

ensure that care plan is delivered as expected

December 2013

Crisis Response

40

• A function within the specialist intermediate care team• Currently mainstream services cannot always mobilise services quickly enough to

maintain the person at home• A team of trained but unqualified staff who can respond to referrals and provide

care within 2 hours; clinical input will be via the specialist intermediate care team• Available 24/7• Able to support patients who are currently at home as well those who may have

attended A&E but do not require hospital admission• It is expected that:

• 90% of patients will be transferred to the main specialist intermediate care service, other mainstream services or discharged within 3 days

• 100% of patients will be discharged or transferred within 7 days• Likely to be based at Kings Mill Hospital and Newark Hospital

December 2013

Enhanced Intermediate Care Model

41

• Intermediate care is the vehicle / enabler which will control the flow in and out of hospital and drive the right patient into the right place.

• Three Key Elements:• Admissions avoidance ( Proactive care and Step Up) • Support for early discharge • Rehabilitation and Reablement

• Evidence shows that patients have better outcomes when managed in their own homes – esp FOP’s

• National policy direction to move away from fixed beds and increase provision of IC in the community

• Care in the patients home as default with use of fixed beds only when level of support required precludes the option – ( ie requires 24 hour nursing or medical supervision)

• Move away from and balance current focus on step down to increase focus on step up to stop people getting to hospital in the first place.

December 2013

Specialist Intermediate Care Team working across three key areas

42

• Front Door to support discharge to assess or admission plans• Discharge planning on admission and coordination and delivery of discharge on

the wards• Provision of post discharge support / and care in the community including crisis

response• Up to 14 days intensive rehab • Hand over to Virtual ward / MDTs for longer term support

• Staff rotating across all three functions• Access to “fixed” beds for patients who cannot be managed in their own homes

• MCH / Fernwood/ Existing IC Beds• Care Homes

December 2013

Front door at A&E

43

• Integrated booking in and triage systems between current PC24 and A&E service• Enhanced team at front door to include GP, specialist intermediate care, ANP for

frail older people; increased consultant paediatrician presence• Signpost patients to other services following symptom relief and reassurance• Maximise see and treat• Maximise ambulatory care (upper quartile performance)• Enhanced function within specialist intermediate care to provide immediate

December 2013

Fit with National Policy

44

• Addresses the proposals in the national review of urgent and emergency care, phase 1 (with the exception of designation of A&E departments)

• In line with the new enhanced service for the GMS contract• Design for intermediate care reflects recommendations made in National Audit of

Intermediate Care 2013.

December 201345

Benefit / Impact ( over 5 years)

Activity• Non-elective Admissions ( SFHT) Reduction of 19.5%• A&E Attendances (SFHT) Reduction of 15.1%• Occupied/Excess bed days (SFHT) Reduction of 12.6%• Non –elective readmissions ( all providers) Reduction of 10%• Demand for Long Term Residential care Reduction of 25%

Above activity delivers in line with Blueprint assumptions

Financial• Re- Provision costs slightly lower than Blueprint• Financial benefits being worked up and will be shared within formal business

cases being presented to Governing Bodies in February 14.

Any Questions?

Thank You

For further information please contact:Jan BalmerAssociate Director – Integration and Unplanned Carejan.balmer@newarkandsherwoodccg.nhs.uk

Tel: 07734 296846

Transforming Care for People with Long Term Conditions