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8 June 2011

Integrated Care Pilot Launch event. 8 June 2011. Agenda. Welcome and Introduction 11:30-11:35. What is the integrated care pilot? 11:35-11:50. A brief overview of the IT support tool 11:50-11:55. What’s happening on the ground - Acton 11:55-12:00.

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8 June 2011

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  1. Integrated Care Pilot Launch event 8 June 2011

  2. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  3. Prof. Elisabeth PaiceChair, Integrated Management Board

  4. Integrated care can deliver benefits forpatients, clinicians and the wider health system Improve quality of patient care Create a richer professional experience Efficient use of NHS funds

  5. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  6. Dr. Aumran TahirCo-Director, Integrated Care Pilot

  7. 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. Providing joined up care for patients is the central idea of the ICP SOURCE: NWL interviews

  8. 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 Background for Integrated care inNorth West London – for people with diabetes and the elderly

  9. 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 5 Sub-Group Patient registry Care delivery Practice 2 6 Mental Health Specialist Risk stratification Case conference GP District nurse Community matron 3 7 Clinical protocols & care packages    Performance review Acute Specialist 4 Practice nurse Social care worker Community Mental Health Care plans Social care Specialist What’s the big idea?

  10. 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

  11. 7 Performance review    1 2 4 Patient registry Risk stratification Care planning 5 Care delivery1 GP Practice nurse 6 Case conference Districtnurse Social care worker 3 Shared clinical protocols Community pharmacist Community Mental Health What does the Multi-Disciplinary system consist of? 1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review

  12. Catchment Pilot Practice GP Providing integrated care can have a significant impact for the patients and for the health system as a whole • Save 2,215 avoidable admissions per year across the pilot population of 375,000 • Save 4,430 avoidable admissions per year across the catchment population of 750,000 • Save 12 avoidable admissions per year per ~2,000 patients • Save 48 avoidable admissions per year per ~8,000 patients • 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

  13. Reduction in Activity The pilot will also be evaluated on four other key dimensions Evaluation Metrics for IC Pilot Impact on Operations Quality of Care • 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 • Attendance at MDGs • Staff-satisfaction with IC pilot • Quality of MDG interaction • Emergency admissions • A&E attendances • Emergency inpatient days • Prescriptions SOURCE: Evaluation Working Group

  14. Chair of Integrated Management Board General Practice Acute providers Community Health Local Authorities MentalHealth Patient reps and third sector • 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 The pilot will be governed via an Integrated Management Board (IMB) which is an association of all participating members

  15. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  16. Dr. David GableConsultant, Imperial College Healthcare NHS TrustLead Clinician, Westminster Diabetes Partnership

  17. Care plan Action 1 Action 2 Action 3 The pilot is supported by a custom IT portal which enables four key elements of integrated care 1 2 Risk stratification Care Planning Action: Review by falls service Action status: Completed • Identify high risk patients using population segmentation and risk stratification • This enables proactive care to be planned • Plan care for patients, share these plans across settings, and monitor progress • This helps better coordinate care 3 4 Information Sharing 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

  18. 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

  19. 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

  20. 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

  21. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  22. Dr. Jennifer DurandtGP Mill Hill surgeryActon

  23. 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

  24. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  25. Chris HamChief Executive, King's Fund

  26. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  27. What does the ICP pilot mean for you, your organisation and your patients? • Dr. Mark Spencer Medical Director NHS North West London GP, Hillcrest surgery Acton • Dr. Jonathan Valabhji Consultant Physician Imperial College Healthcare • Dr. Iňaki Bovill Consultant Physician Chelsea and Westminster Hospital • James Reilly Chief Executive Central London Community Healthcare • Roz Rosenblatt London Region Manager Diabetes UK • Benn Keaveney Age UK • Cath Attlee Assistant Director Joint Commissioning Westminster City Council

  28. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  29. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  30. Anne RainsberryChief Executive, NHS North West London

  31. New way of working • Factors for success What’s different about the integrated care pilot? • Multidisciplinary groups where generalists work alongside specialists to deliver integrated care • Patient and clinician driven • Collaborative culture • Model based on aligned financial incentives • Use of guidelines and internationalbest practice • Shared accountability for performance • IT supports delivery

  32. What’s next for integrated care in North West London? • Roll out across more practices in North west London • Enhance integration with local authorities and other providers • Continue to develop and enhance the IT tool • Conduct robust evaluation at the end of the pilot year to track impact

  33. Working together we can make the Integrated care pilot a real success

  34. Agenda • Welcome and Introduction 11:30-11:35 • What is the integrated care pilot? 11:35-11:50 • A brief overview of the IT support tool 11:50-11:55 • What’s happening on the ground - Acton 11:55-12:00 • Importance of integrated care in NHS 12:00-12:10 • Panel discussion 12:10-12:35 • Questions and Answers 12:35-12:45 • Summary and wrap up 12:45-12:50 • Refreshments and networking 12:50-13:30

  35. Appendix • A0 Posters

  36. What are we trying to achieve in NWL? Background for Integrated care inNorth 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 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

  37. Mental Health Specialist    Acute Specialist Social care Specialist 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 5 Sub-Group Patient registry Care delivery Practice 2 6 Risk stratification Case conference GP District nurse Community matron 3 7 Clinical protocols & care packages Performance review 4 Practice nurse Social care worker Community Mental Health 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

  38. 3 Shared clinical protocols What does a Multi-Disciplinary Group do? 1 2 7 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 The MDG uses the ICP information tool to stratify these patients by risk of emergency admission The MDG meets regularly to review its performance and decide how it can improve its ways of working to meet the Pilot goals 7 Performance review    4 1 2 Care planning Patient registry Risk stratification 5 Care delivery1 GP Practice nurse 6 Case conference Districtnurse Social care worker Community pharmacist Community Mental Health 3 4 5 6 All providers in the MDG agree to provide high quality care as laid out in the Pilot’s recommended pathways and protocols 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 A small number of the most complex patients will be discussed at a multi-disciplinary case conference, which will help plan and coordinate care Each patient is then given an individual integrated care plan that varies according to risk and need 1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review

  39. Care plan Action 1 Action 2 Action 3 The pilot is supported by a custom IT portal which enables four key elements of integrated care 1 2 Risk stratification Care Planning Action: Review by falls service Action status: Completed • Identify high risk patients using population segmentation and risk stratification • This enables proactive care to be planned • Plan care for patients, share these plans across settings, and monitor progress • This helps better coordinate care 3 4 Information Sharing 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

  40. 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

  41. 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

  42. 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

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