Integrating Care across Mid Nottinghamshire

1. Integrating Care across Mid Nottinghamshire Transforming Care for People with Long Term Conditions and the Frail Elderly

2. Our financial challenge • 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. 5 Year Financial gap = £70m 10 year Financial gap = £140m

3. INTEGRATED CARE Locality teams Self-management 100% Third sector provision SHIFT LEFT Long Term Condition Management incl Cancer Primary Care COMMUNITY CARE ACUTE CARE Consultant-led services Specialty Clinic Specialist teams Planned procedures ICU 0% £1 £10 £100 £1,000 £5,000 We have a vision for the next five years Quality of life Risk profiling Cost of Care per Day

4. 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

5. 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 Conditionsand 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

6. 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

7. Integrating the management of cancer as a long term condition

8. 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.

10. 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

11. Risk Stratification

12. 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

13. Mid Nottinghamshire Integrated Model of Care for Long Term Conditions Workforce Development, Training and Education Smoking Cessation, Health Promotion and Self Care Low RISK / Complexity HIGH RISK / Complexity Level Devon Tool for Systematic Risk Profiling to identify risk 1 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 and Health promotion 2 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 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 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 Public Health Population wide Prevention Disease awareness campaigns Social marketing Education Health promotion Schools 3 4 Co-ordinated Social Care Care Coordinator / Named Lead Special Patient Notes / 24/7 Access to specialist support Admissions Avoidance

15. Integrated Care

16. 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

17. 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)

18. Community Specialist Teams Diabetes/ COPD/ Heart Failure/ Cancer Level 3 Case Management Step Up Step Down between level 3 and level 4 ( Virtual ward) Newark and Sherwood Integrated Team Model- LOCALITY VIEW 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. Named Community Geriatrician Named Specialist Nurse COPD HF Diabetes Cancer Linked to Dietetics Tissue Viability 2 Social Worker GP Access to & Support from Mental Health Professional Community Support Workers Key Continence Monthly RiskStratification Community Matrons GP GP Practices/ Primary Care Ward Co-Ordinator Comm munity Pharmacy Community Nurses Physiotherapist Locality specific Virtual Ward / MDTs x 3 Intermediate Care GP Healthcare Assistants Occupational Therapist EMAS/ CNCS/ OOHs Cross locality support teams working across all localities and specialist disease management teams Podiatry Medicines Management Virtual Ward Core Team Voluntary Services Named Community Oncologist CCG wide services Falls Team Extended Team Support across all localities Specialist Community Teams – disease specific. Level 3 case management Crisis Response / Rapid Intervention Service

19. Mid Nottinghamshire Integrated Model of Care for Long Term Conditions Workforce Development, Training and Education Smoking Cessation, Health Promotion and Self Care Low RISK / Complexity HIGH RISK / Complexity Level Devon Tool for Systematic Risk Profiling to identify risk 1 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 and Health promotion 2 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 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 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 Public Health Population wide Prevention Disease awareness campaigns Social marketing Education Health promotion Schools 3 4 Co-ordinated Social Care Care Coordinator / Named Lead Special Patient Notes / 24/7 Access to specialist support Admissions Avoidance

20. Systematisation of Self Care

21. 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

22. 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

23. What Have We Achieved to Date?

24. KPI Monitoring for PRISM – 10% reduction in emergency admissions for COPD, Diabetes and Heart Failure Newark Team Go Live North Team Go Live West Team Go Live 24

25. Newark & Sherwood Emergency Admissions per 1,000 patients by Practice May 13 to July 13 25

26. 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

27. 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!

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

29. 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

30. The New Integrated Urgent & Proactive Care Model for Mid Nottinghamshire

31. 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 COMMERCIAL IN CONFIDENCE

32. 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.” Helping to shape future health and social care in Mid Nottinghamshire COMMERCIAL IN CONFIDENCE

33. 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 Nottinghamshire COMMERCIAL IN CONFIDENCE

34. The consequences of being ambitious are less scary than not being ambitious enough…. Helping to shape future health and social care in Mid Nottinghamshire COMMERCIAL IN CONFIDENCE

35. Principles underpinning the design of the proactive and urgent care system • 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

36. Key: Proactive and Urgent care model Away from the community Proactive care Self Care Towards community Urgent Care SICT Crisis notification Care in the patient’s home Care navigation Acute care A more responsive primary care service Self care Maintain independence Self Care Hub Healthy living & wellbeing PRISM plus Communicating effectively with the public Acute Medical Emergency Care Navigator Acute care Proactive care Risk Stratification Determine necessary care package and deploy services MDTs GP/OoH EMAS Social Care A&E/ MAU/ WARD Specialist Intermediate Care Team Virtual wards / MDTs Crisis Response Team Back door Single Front Door Intermediate care in the home Bedded Intermediate Care Discharge coordination Low level support Enhanced support Intensive support Low level support Enhanced support Intensive support

37. Self Care • 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

38. Virtual Ward MDT • 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

39. Care navigator • 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

40. Crisis Response • 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

41. Enhanced Intermediate Care Model • 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.

42. Specialist Intermediate Care Team working across three key areas • 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

43. Front door at A&E • 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

44. Fit with National Policy • 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.

45. 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.

46. Thank You Any Questions?

47. For further information please contact:Jan BalmerAssociate Director – Integration and Unplanned Carejan.balmer@newarkandsherwoodccg.nhs.ukTel: 07734 296846 Transforming Care for People with Long Term Conditions