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Camden Provider Services Integrated Primary Care Stephen Meechan Service Line Manager, Integrated Primary Care Wednesda

Camden Provider Services Integrated Primary Care Stephen Meechan Service Line Manager, Integrated Primary Care Wednesday, 26 th June 2013 stephenmeechan@nhs.net. Our locations Our core services District Nursing Frailty pilot function Community rehabilitation

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Camden Provider Services Integrated Primary Care Stephen Meechan Service Line Manager, Integrated Primary Care Wednesda

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  1. Camden Provider Services Integrated Primary Care Stephen MeechanService Line Manager, Integrated Primary Care Wednesday, 26th June 2013 stephenmeechan@nhs.net

  2. Our locations Our core services District Nursing Frailty pilot function Community rehabilitation Rapid Response service PACE Developments Overview

  3. IPC in numbers… • Camden has a population of circa 212,000 • There are 5 integrated Primary Care base Locations • Caseload of around 3,000 • Over 10,000 contacts per month Kentish Town Belsize Priory St Pancras Hospital Gospel Oak Hunter Street

  4. Our Core Services Daytime District Nursing Frailty Pilot Community Rehabilitation REDS Rapid Response PACE Evening and Overnight District Nursing Community Phlebotomy

  5. District Nursing Operating from four health centres around Camden. Nursing care for housebound patients, e.g. wound care and medication management. 9,000 Contacts per month. Staffed by 75-80 nursing staff. Evening and Overnight service from St Pancras. Night service for Islington as well as Camden.

  6. Frailty Pilot Targets patients with complex needs/frailty. Uses Edmonton Frail Scale and contributes to multidisciplinary assessment, care plan development and implementation and outcome monitoring. To develop better working partnerships that facilitate integrated, coordinated ways of communicating and delivering care between Primary, Secondary, Community, Health and Social care services. Aims to shift unscheduled care episodes into a planned coordinated integrated community service of care with GPs playing an important role. It is anticipated though that by improving outcomes in these patients not only will there be a reduction in unscheduled care episodes but also demands on other services including the GP. Integrated primary care provides frailty assessment and care planning

  7. Community Rehabilitation Operating from four health centres around Camden. Providing physiotherapy and occupational therapy to housebound patients. 500 Contacts per month. 25 Staff. Up to 6 week programme of therapy and Carelink re-enablement to facilitate early hospital discharge and reduce long term care burden. Managed by each health centre community rehabilitation team, centrally screened by Camden Central Access Team. Early Discharge Service

  8. Rapid Response Service One Community Matron & one Occupational Therapist. Operational 9–5 Mon–Fri with 3pm cut off for referrals. Up to 10 days of intervention: admissions avoidance. Can access Carelink for supportive care package. Recent expansion (Feb-March 2013) with large saving in bed days for local acutes.

  9. PACE (Post Acute Care Enablement) Early Discharge service for Royal Free patients. Intensive community support for five days following discharge (with patient still under Consultant). PACE Step Down recently introduced, giving support for a further seven days.

  10. Under development Expanded and integrated admissions avoidance and early discharge team. TeleHealth and TeleCare: Programme manager to expand provision starting soon Patient self-management Pilot programme. Needs-based referrals via a single point of access.

  11. Questions ?

  12. Self management in Medicine Administration Sue Elvin Nurse Consultant DN Louise Phillips IPC Therapy Lead

  13. Self management Medicines: The challenge now Approx 50% of nursing caseload is for medicines administration No standard process for assessing self management potential or managing risk Unclear how and why support is provided in many cases (health vs social care vs informal) Historically a nursing domain but could use and share knowledge within integrated teams

  14. Self management Background Literature review and evidence base Use best practice examples as a foundation Work using an integrated, multi-agency approach Establish tools that are easy & practical

  15. Self management SM in Medicines: the Tools • Tools were developed as part of previous pilot trial: • MedMaIDE: Medication Management Instrument for Deficiencies in the Elderly • Solution-based flowcharts • Action plan, including risk management, which can form part of the care plan

  16. Self management SM in medicines: Assessment • MedMaIDE enables assessment in categories: • Knowledge about medicines • How to take medicines • How to get medicines • Provides a score. Anything above 0 indicates a problem with self management

  17. Self management Solution focused intervention Flowcharts developed to guide clinicians towards solutions in each category Encourages true integrated working Encourages creative problem-solving and goal-setting Provides evidence of why & if the client needs help and for what tasks exactly.

  18. Self management Support Solutions Enabling people as much choice and independence as possible. Keep people safe, with clear risk management plans. Support should be based on need Consider the best method and type of support, whether the need is for informal or social care, pharmacy or nursing input.

  19. Self management Next steps CQUIN target for 2013/14

  20. Self management Project Plan R E V I E W

  21. MDT Hub Case Study Sue ElvinNurse Consultant, Integrated Primary Care Wednesday, 26th June 2013

  22. Vulnerability of frail elderly people to a sudden change in health status after a minor illness

  23. Complex interventions based upon comprehensive geriatric assessment can increase likelihood of continuing to live at home Exercise can improve outcomes Interventions Beswick et al. Lancet 2008; 371: 725-35 Forster A et al. Cochrane Database Syst Rev 2009; 1: CD004294

  24. It will take time • Nuffield Trust review of first year of inner North London integrated care pilot May 2013 has not yet shown a reduction in admissions or significant change in wider use of services: • ‘but 3-5 years is probably needed to show impact’ • Nuffield Trust. • Evaluation of first year of the inner North West London integrated care pilot. • May 2013. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/evaluation_of_the_first_year_of_the_inner_north_west_london_integrated_care_pilot.pdf.

  25. Benefits • Reduction in long term institutional care • High levels of patient satisfaction • Improvements in self-reported health and mental health D’Souza & Guptha Preventing admission of older people to hospital BMJ 2013; 346: f3816

  26. Integrated Care and Support: Our Shared Commitment • Frailty pathway broadly fits in with government’s new desire to see a fully integrated system of health and social care in England: • Announced by Norman Lamb mid-May 2013 • ‘Integrated care Pioneer sites’

  27. Why is Camden piloting this? • Virtual ward pilot demonstrated fragmentation of care, which impacted upon clinical efficiency as well as clinical and patient outcomes (and therefore cost). • Camden’s commissioning intentions are to embrace collaborative working at all levels to drive up quality and value in Long Term Condition service delivery

  28. Rationale for the Frailty LES • Prevention of avoidable hospital activity • Patients aged 64+ non elective admission • 2011/12: 5,900 • 2012/13: 6,000 • 42% resulted in stays of 2 days or less • Improving outcomes and patient experience through better co-ordination of care • 35% of older people admitted to hospital are discharged in a poorer functional state than on admission • Continuity of GP care can prevent emergency admissions (Baker et al 2012)

  29. Frailty LES care planning process

  30. Comprehensive geriatric assessment • Multi-level evaluation: • Functional status • Cognition • Psychological status • Social support • Nutritional status • Co-morbidity • Medications • Evidence-based process to detect and grade frailty but resource-intensive

  31. Hub MDT • Weekly multidisciplinary meeting: • GP • Geriatrician / secondary care • Nurse consultant • District nurses • Therapists • Social workers • Mental health worker • LAS co-ordinator • Pharmacist

  32. Competition time! • Who can identify the following slide?

  33. Patient: Mr A • Referral to Hub MDT presented by social worker 30/01/2013 • Lung cancer (review) • Radiotherapy completed last year, has follow-up soon but no further treatment planned. • Cerebrovascular disease (Review) • Hazardous alcohol use (Review) • Recent admission to hospital with fall and hyponatraemia ? secondary to heavy alcohol use. Self-discharged. • Recent suicidal ideation due to partner leaving and death of close friend, mood has improved according to SW. • Pt has poor mobility. • Cigarette smoker 60 /day: concern about fire risk. • Drug compliance poor: taking meds from various blister packs.

  34. Overview of frailty pathway for Mr A

  35. Background information • Suicidal ideation, heavy drinking, GP found it difficult to refer to crisis team • Crisis team refusing to take referral until patient had been reviewed by GP

  36. The CAARE model • Consider – if a person is vulnerable (This would usually takes place during the referral process) • Assess whether a person is frail (This would usually take place during the referral process using the Edmonton Frailty Scale) • Assess need – comprehensive assessment • Respond to needs with timely, appropriate and co-ordinated interventions • Evaluated – the service provision and care plan will be evaluated according to whether care delivery and patient focused outcomes are achieved.

  37. Medical history of note included • Right Lacunar Infarct 16/11/11, full community support from REDS/REACH • ?Squamous Cell CA lung found on investigation during stroke, subsequent radiotherapy • Back pain-S1 nerve root slight compression, • PVD, Hypertension, • Hoarse voice-seen by ENT-no cause found, • Smokes 60 per day, flat is very evident of the effects of this and it can be very smoky in the flat • Low mood • ?10 year history of depression, • Bouts of heavy drinking ?1/2 bottle of whisky per day: although sober during initial assessment • January 2013 suicidal ideation

  38. Problem list identified at Frailty assessment: Risks • Smoking • Fire to self & neighbours in low rise block of flats • Food-10 packets of sandwiches not in fridge • Access to flat • Communication with Mr A • Medications • Alcohol consumption • Falls • Varying degrees of insight by patient

  39. Problem list identified at Frailty assessment • Pain • Tires easily • Constipation • Poor mobility • Vision-no eye test 20years • Poor state of mouth- 3 decaying teeth left • Default resistant to help • Worried re finance • Medicines • Prognosis unclear • ? EoL plan • Nutrition • Varying ability to self care • Bereft • Lonely • Cold, dark flat

  40. Frailty assessment • Joint visit Nurse Consultant, SW, Community Nurse • Immediate issue to resolve excess medications. • Challenge: Aim to agree prioritisation of problem list with patient, however…

  41. Medications • Patient unclear/poor history of how meds taken • 2 blister packs in chaotic use, patient reports “occasionally gets mixed up” and reported having taken the evening dose in the morning which made him drowsy. • packets of other medication being stored next to a very hot radiator in the lounge. • several packets of Morphine 10mg Sulphate tablets patient states he no longer uses. • 4 bottles of morphine liquid patient states he no longer uses • boxes of Naproxen • Patient reports cupboards full of medicines around the house-Indeed!

  42. Care Plan re: Medications • Medication review at home by IPC Senior Pharmacist-4 carrier bags of drugs removed • Shared care plan at home of medication management • Immediate removal of CDs to local pharmacy • Liaise/action plan with GP re medications, pain control

  43. Other Care Plan highlights • Excellent joint working in IPC Locality Team PT, OT & IC SW • Micro environment set up • Joint visit to St Marys Oncology Appt • Case management with a focus on pain control-commenced Weekly Butrans patches

  44. IPC OT Analysis • Functionally & cognitively pt appears very well in self as per this visit. Pt appears to fluctuate greatly in therapy intervention from being fairly independent (i.e. today mobilising without aid & able to do stairs with ease) to struggling with his mobility (as initially seen by OT when pt was able to mob approx 1 m with r/frame & struggled with transfers). It is anticipated that his cognition may also fluctuate, for example today pt MMSE showed no cause for concern however yesterday pt was unable to problem solve the issue of not having any food in the house & it was only due to call of OT that this issue was raised.

  45. Interesting facts • 22 different services/voluntary organisations now involved-Joint visits, referrals • 76 emails

  46. Benefits • Hmm…. • Patient feels ‘that we really care about him’ • Giving up smoking! • GP pleased with support & input • Joint working

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