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Integrated Care Pilot Launch Event

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Integrated Care Pilot
Launch event
8 June 2011
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
1
Prof. Elisabeth Paice
Chair, Integrated Management Board
2
Integrated care can deliver benefits for
patients, clinicians and the wider health system
Improve quality of patient care
Create a richer professional experience
Efficient use of NHS funds
3
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
4
Dr. Aumran Tahir
Co-Director, Integrated Care Pilot
5
Providing joined up care for patients is the central idea of the ICP
SOURCE: NWL interviews
Joe, 85 years old, mild dementia,
lives at home with his wife Annie. He
develops a low-grade urine infection
and as a result is increasingly
confused and has reduced mobility.
Joe would be indentified as patient in need of an
integrated care plan. His care plan would be
available to all health care professionals involved in
his care and in the ICP. Crucially he and his carer
would have a copy of the care plan.
Annie contacts the Out of hours
service whose GP prescribe
antibiotics and ask the District nurses
to visit.
Had there been integration with health care
providers Joe would have had a social worker
assigned and contact details of all professionals
would be available.
The DN visits the next day and asks
Annie to contact the council for
additional help. At the council, Suzie
tells them she needs some time to
sort out the paperwork
If Suzie had integrated IT systems and access to
Joe’s care records; she would have known that Joe
is an individual who required additional care quickly.
She may have already put in place additional support.
Meanwhile, Joe, falls on the way to
the toilet and breaks his hip. At the
hospital, he has hip surgery and his
memory deteriorates.
By focusing on preventative care and the
promotion of well-being, for example Joe may have
been indentified as needing a falls assessment and
fracture prevention.
Annie is unable to look after him at
home any more, so Joe is discharged
to a nursing home after a lengthy stay
in hospital.
Even if Joe’s fall couldn't have been avoided and he
was admitted to hospital; community care would
have known about Joe’s condition and planned for a
speedy discharge.
6
Background for Integrated care in
North West London – for people with diabetes and the elderly
Practices serving up to 375,000 patients are already working with the pilot to
start delivering integrated care for their patients with diabetes and the elderly
Over the
course of the
pilot we aspire
to transform
care for a
population of
750,000
people across
six boroughs
Acton: ~54,000
patients
Westminster:
~63,000 patients
Hounslow:
~40,000
patients
Hammersmith
and Fulham:
~185,000
patients
Kensington and
Chelsea:
~35,000 patients
7
What’s the big idea?
Improve the quality of patient
care for patients with diabetes and the elderly
Local Multi-Disciplinary Groups…
…working in a Multi-Disciplinary System
Group
1
Sub-Group
5
Patient
registry
Care
delivery
Practice
Social care
Specialist
2
6
Risk
stratification
GP
Practice
nurse
District
nurse
Social
care
worker
Community
matron
Community
Mental
Health
Mental
Health
Specialist
3
Clinical
protocols &
care packages
Case
conference
7
Performance
review
пѓј
пѓј
пѓј
4
Acute
Specialist
Care plans
8
What are the key enablers?
Patient, user and carer engagement and involvement
Joint Governance through IMB with a shared performance and
evaluation framework
Aligned Incentives through an innovative financial model
Information sharing to access and analyse data in a timely
fashion
Organisation and culture development
9
What does the Multi-Disciplinary system consist of?
7
Performance review
пѓј
пѓј
пѓј
1
Patient registry
2
Risk stratification
4
Care planning
5
Care delivery1
GP
Practice nurse
6
3
District
nurse
Social care
worker
Community
pharmacist
Community
Mental Health
Shared clinical protocols
Case conference
1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review
10
Providing integrated care can have a significant impact for the patients
and for the health system as a whole
GP
в–Є Save 12 avoidable
admissions per year
per ~2,000 patients
Practice
в–Є Save 48 avoidable
admissions per year
per ~8,000 patients
Pilot
Catchment
в–Є Save 2,215 avoidable
в–Є Save 4,430 avoidable
admissions per year
across the pilot
population of 375,000
admissions per year
across the catchment
population of 750,000
в–Є In the steady state the pilot aims to save 1 avoidable emergency admission per GP per month by
providing more joined up planned care to patients in the pilot pathways
11
The pilot will also be evaluated on four other key dimensions
Evaluation Metrics for IC Pilot
Quality of Care
Impact on Operations
в–Є
в–Є
в–Є
в–Є
в–Є
в–Є
в–Є
в–Є
в–Є
в–Є
в–Є
в–Є
Acute re-admissions
Control measures
Reduction in long-term care needs
Waiting lists for non-acute care
Hard outcomes (incl. PROMs)
Patient experience metrics (incl. PREMs)
Patients on care plan
Adherence to care plan
Average length of stay
Quality of care planning
Community nursing hours per patient
Bed occupancy rate
Staff engagement
Reduction in Activity
в–Є Attendance at MDGs
в–Є Staff-satisfaction with IC pilot
в–Є Quality of MDG interaction
в–Є
в–Є
в–Є
в–Є
SOURCE: Evaluation Working Group
Emergency admissions
A&E attendances
Emergency inpatient days
Prescriptions
12
The pilot will be governed via an Integrated Management Board (IMB)
which is an association of all participating members
Chair of Integrated
Management Board
General
Practice
Acute
providers
Patient reps
and third
sector
Community
Health
Local
Authorities
Mental
Health
в–Є The legal documents signed by all the parties also facilitate
– Creation of IMB and its processes and procedures
– Assure process around funding flows
– Setting of the information governance framework allowing access to the IT tool
– Arrangements for data sharing among the ICP Partners
– Ensure mutual accountability and collective decision making
13
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
14
Dr. David Gable
Consultant, Imperial College Healthcare NHS Trust
Lead Clinician, Westminster Diabetes Partnership
15
The pilot is supported by a custom IT portal which enables four key
elements of integrated care
1 Risk stratification
2 Care Planning
Care plan
Action: Review
by falls service
Action 1
Action 2
Action 3
 Identify high risk patients using population
segmentation and risk stratification
Action status:
Completed
 Plan care for patients, share these plans across
settings, and monitor progress
 This enables proactive care to be planned
 This helps better coordinate care
3 Information Sharing
4 Evaluation
Patient records:
GP
Hospital
Community
 View patient medical information from multiple

settings
This enable integrated care to be provided
 Track and evaluate the performance of GP’s surgeries

and Multi-Disciplinary Groups
This helps spread best practice in patient care
16
The ICP Web Portal can be used to identify high risk patients
The risk stratification screen allows health care
professionals to identify high risk patients
A number of different metrics can be used to help in
this task
They can then click on any of the bars in the graph
to see which patients fall into that risk category
17
Integrated Care Plans help coordinate the care for patients within the Pilot
The Portal can be used to create and manage
Integrated Care Plans for patients
Text
Standard care packages can be selected by clicking
on any of the template buttons, the actions in this
care plan will then be selected
Individual actions can then be added or removed
from the care plan
18
The portal can also be used to share patient information across settings
This screen shows some basic information about the
patient
It also shows the patients prescription history
The prescription history can be filtered and sorted to
better be able to find information
19
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
20
Dr. Jennifer Durandt
GP Mill Hill surgery
Acton
21
What’s happening in Acton?
What's new?
Twelve practices…
…serving 54,000
patients…
…with a new full time
elderly care specialist
nurse and additional
diabetes specialist
sessions…
…and a new email
service connecting
GPs and acute
consultants…
…supported by monthly
Multi-Disciplinary
Case Conferences for
discussing complex
patient cases
22
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
23
Chris Ham
Chief Executive, King's Fund
24
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
25
What does the ICP pilot mean for you, your
organisation and your patients?
в–Є
Dr. Mark Spencer
Medical Director
NHS North West London
GP, Hillcrest surgery Acton
в–Є
Dr. Jonathan Valabhji
Consultant Physician
Imperial College Healthcare
в–Є
Dr. IЕ€aki Bovill
Consultant Physician
Chelsea and Westminster Hospital
в–Є
James Reilly
Chief Executive
Central London Community Healthcare
в–Є
Roz Rosenblatt
London Region Manager
Diabetes UK
в–Є
Benn Keaveney
Age UK
в–Є
Cath Attlee
Assistant Director Joint Commissioning
Westminster City Council
26
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
27
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
28
Anne Rainsberry
Chief Executive, NHS North West London
29
What’s different about the integrated care pilot?
New way of
working
Factors for
success
в–Є
Multidisciplinary groups where generalists
work alongside specialists to deliver
integrated care
в–Є
Patient and clinician driven
в–Є
Collaborative culture
в–Є
Model based on aligned financial incentives
в–Є
Use of guidelines and international
best practice
в–Є
Shared accountability for performance
в–Є
IT supports delivery
30
What’s next for integrated care in North West London?
в–Є
Roll out across more practices in North west
London
в–Є
Enhance integration with local authorities and
other providers
в–Є
Continue to develop and enhance the IT tool
в–Є
Conduct robust evaluation at the end of the pilot
year to track impact
31
Working together we can make the Integrated care pilot a real success
32
Agenda
в–Є
Welcome and Introduction
11:30-11:35
в–Є
What is the integrated care pilot?
11:35-11:50
в–Є
A brief overview of the IT support tool
11:50-11:55
в–Є
What’s happening on the ground - Acton
11:55-12:00
в–Є
Importance of integrated care in NHS
12:00-12:10
в–Є
Panel discussion
12:10-12:35
в–Є
Questions and Answers
12:35-12:45
в–Є
Summary and wrap up
12:45-12:50
в–Є
Refreshments and networking
12:50-13:30
33
Appendix
A0 Posters
34
Background for Integrated care in
North West London – for people with diabetes and the elderly
Practices serving up to 375,000 patients are already working with the pilot to
start delivering integrated care for their patients with diabetes and for the elderly
Over the course
of the pilot we
aspire to
transform care
for a population
of 750,000
people across
five boroughs
Acton: ~54,000
patients
Westminster:
~63,000 patients
Hounslow:
~40,000
patients
Hammersmith
and Fulham:
~185,000
patients
1)
What are we
trying to
achieve in
NWL?
2)
3)
4)
Kensington
and Chelsea:
~35,000 patients
Become a �beacon’ for delivering integrated care to the local population involving primary,
secondary, community, social and mental health sectors
Significantly improve patient experience
Decrease emergency admissions by 30% and nursing home admissions by 10% for diabetics
and frail elderly through better more proactive care
Reduce the cost of care for these groups by 24% over 5 years
35
What’s the big idea?
Improve the quality of patient
care for patients with diabetes and the elderly
Local Multi-Disciplinary Groups…
…working in a Multi-Disciplinary System
Group
1
Sub-Group
5
Patient
registry
Practice
Social care
Specialist
2
Care
delivery
6
Risk
stratification
GP
Practice
nurse
District
nurse
Social
care
worker
Community
matron
Community
Mental
Health
Mental
Health
Specialist
3
Clinical
protocols &
care packages
Case
conference
7
Performance
review
пѓј
пѓј
пѓј
4
Acute
Specialist
Care plans
Patient, user and carer engagement and involvement
Joint Governance through IMB with a shared performance and evaluation framework
Aligned Incentives through an innovative financial model
Information sharing to access and analyse data in a timely fashion
Organisation and culture development
36
What does a Multi-Disciplinary Group do?
1
2
Each MDG holds a register
of all patients who are over
the age of 75 and/or who
have diabetes – these
patients are part of the Pilot
1
Patient registry
7
7
The MDG uses the ICP
information tool to stratify
these patients by risk of
emergency admission
2
Risk stratification
4
Care planning
The MDG meets regularly to
review its performance and
decide how it can improve its
ways of working to meet the
Pilot goals
Performance review
пѓј
пѓј
пѓј
5
Care delivery1
GP
Practice nurse
6
3
District
nurse
Shared clinical protocols
Case conference
Social care
worker
Community Community
pharmacist Mental Health
3
All providers in the MDG agree to
provide high quality care as laid
out in the Pilot’s recommended
pathways and protocols
4
5
Each patient is then given an
individual integrated care plan that
varies according to risk and need
Patients receive care from a range
of providers across settings, with
primary care playing the crucial
co-ordinating role and every body
using the ICP IT tool to coordinate
delivery of care
6
A small number of the most
complex patients will be discussed
at a multi-disciplinary case
conference, which will help plan
and coordinate care
1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review
37
The pilot is supported by a custom IT portal which enables four key
elements of integrated care
1 Risk stratification
2 Care Planning
Care plan
Action: Review
by falls service
Action 1
Action 2
Action 3
 Identify high risk patients using population
segmentation and risk stratification
Action status:
Completed
 Plan care for patients, share these plans across
settings, and monitor progress
 This enables proactive care to be planned
 This helps better coordinate care
3 Information Sharing
4 Evaluation
Patient records:
GP
Hospital
Community
 View patient medical information from multiple

settings
This enable integrated care to be provided
 Track and evaluate the performance of GP’s surgeries

and Multi-Disciplinary Groups
This helps spread best practice in patient care
38
The ICP Web Portal can be used to identify high risk patients
The risk stratification screen allows health care
professionals to identify high risk patients
A number of different metrics can be used to help in
this task
They can then click on any of the bars in the graph
to see which patients fall into that risk category
39
Integrated Care Plans help coordinate the care for patients within the Pilot
The Portal can be used to create and manage
Integrated Care Plans for patients
Text
Standard care packages can be selected by clicking
on any of the template buttons, the actions in this
care plan will then be selected
Individual actions can then be added or removed
from the care plan
40
The portal can also be used to share patient information across settings
This screen shows some basic information about the
patient
It also shows the patients prescription history
The prescription history, can be filtered and sorted to
better be able to find information
41
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