PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

ProMISEThe Bromley Programme

Sam Merridale, Programme LeadJune 2012

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

The Local Context

• Large ageing population >16% in 2011• Diabetes, cardiac and respiratory commonest

cause of ill health• Carers and dementia probably under

recognised• Current service delivery often fragmented &

reactive

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

The Vision

Improve the health of our older population with complicated health &

social needs in Bromley

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

The Goals

• Inform patients and promote independence• Identify most vulnerable & over 65• Design care plan around the patient’s needs• Manage their care through coordinating

services effectively

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

The Objectives

• Develop a tool to identify most vulnerable• Create a cohort of people “virtual ward”• Design patient-centred care-plan• Deliver quality service-coordinated, targeted

and appropriate• Promote self-care and education for patient &

carers• Improve communication between care-givers

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

Outcomes

• Improve clinical outcomes, reducing unplanned admissions and length of stay in hospital

• Improve patient’s experience, broadening their understanding of their health needs and self-care measures

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

Developing a Culture Shift

• Key driver is to improve care for our older population

• Need for better respect, improved understanding, shared commitment, opportunities for learning & support->

effective collaborative working

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

The next step-Phase One

• 2 community matrons & 2-3 GP Practices• Testing out the pathway with existing services• Results & progress will inform and enable us

to improve and refine services based on active cases

• Start education programme in primary care

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

Programme Implementation

• Managed process• Programme management team – meet weekly• Agree programme structure, priorities and

case for change• Engagement – critical to success

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

Programme Governance

• Programme Board – responsible for all decisions and moving the programme forward

• Clinical Advisory Group• Stakeholder Reference Group• Programme Implementation Group

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

Accountability

• Health and Wellbeing Board – Financial oversight of shared budget

• Bromley Clinical Commissioning Executive• Bromley, Bexley, Greenwich Programme –

Clinical Strategy Group

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

Stakeholder Engagement

• Primary care clinicians• London Borough of

Bromley• Bromley Healthcare• South London Hospitals

NHS Trust• Oxleas Trust• London Ambulance

Service

• Bromley Links• Bexley CCG• Greenwich CCG• NHS SL Cluster• St Christopher’s• Voluntary Sector• EMDOC• … etc

PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly

Interesting issues!!

• Case finding – using risk stratification, but also clinical knowledge

• Data sharing – across organisational boundaries, and critical to success

• Metrics for evaluation – must be consistent with others

• Telehealth – explore the principles of how this will support true integrated care – it’s not just about expensive gadgets