Integrated care London’s programme of change
1. The benefits of integrated care – learning from North West London 2. Developing the integrated care concept 3. Understanding the potential of integrated care 4. Realising the potential 1
Integrated care can make a big difference for the individual patient… Joe, 85 years old, mild dementia, lives Joe would be indentified as patient in need of an at home with his wife Annie. He integrated care plan . His care plan would be develops a low-grade urine infection available to all health care professionals involved in his and as a result is increasingly care and in the ICP. Crucially he and his carer would confused and has reduced mobility. have a copy of the care plan. Annie contacts the out of hours service Had there been integration with health care whose GP prescribes antibiotics and providers Joe would have had a social worker asks the district nurse (DN) to visit. assigned and contact details of all professionals would be available. The DN visits the next day and asks If Suzie had integrated IT systems and access to Annie to contact the council for Joe’s care records , she would have known that Joe is additional help. At the council, Suzie an individual who required additional care quickly. She tells them she needs some time to sort may have already put in place additional support. out the paperwork Meanwhile, Joe, falls on the way to the By focusing on preventative care and the toilet and breaks his hip. At the promotion of well-being , for example Joe may have hospital, he has hip surgery and his been indentified as needing a falls assessment and memory deteriorates. fracture prevention. Annie is unable to look after him at Even if Joe ’ s fall couldn't have been avoided and he home any more, so Joe is discharged was admitted to hospital; community care would have to a nursing home after a lengthy stay known about Joe ’ s condition and planned for a in hospital. speedy discharge. SOURCE: NWL interviews 2
… and multi -disciplinary groups are instrumental to harness the full impact of integrated care Clinical audit t & perfo rform rmance monito tori ring 3
INWL Integrated Care Pilot (ICP) partners have organised themselves into 9 multi-disciplinary groups (MDGs) that reach over 500K patients CLH Acton K&C North ▪ Practices: 13 ▪ ▪ Practices: 12 Practices: 17 ▪ Diabetes: 2,723 ▪ ▪ Diabetes: 1,551 Diabetes: 2,109 ▪ Elderly: 3,420 ▪ ▪ Elderly: 2,845 Elderly: 3,407 ▪ Total patients: 63,636 ▪ ▪ Total patients: 54,917 Total patients: 74,370 X Victoria Chiswick ▪ ▪ Practices: 8 Practices: 9 ▪ ▪ Diabetes: 1,225 Diabetes: 1,015 ▪ Elderly: 2,618 ▪ Elderly: 2,218 ▪ ▪ Total patients: 47,674 Total patients: 41,630 H&F North Central ▪ Practices: 9 ▪ Diabetes: 2,134 ▪ Elderly: 2,528 ▪ Total patients: 72,486 H&F South Fulham K&C South H&F Central ▪ ▪ ▪ Practices: 6 Practices: 14 Practices: 5 ▪ ▪ ▪ Diabetes: 688 Diabetes: 1,667 Diabetes: 1,113 ▪ ▪ Elderly: 1,700 Elderly: 3,635 ▪ Elderly: 1,790 ▪ ▪ ▪ Total patients: 38,302 Total patients: 73,492 Total patients: 39,908 SOURCE: NWL ICP Operations Team 4
The ICP aims to improve patient outcomes and experience and drive down costs 1) Improve patient outcomes and experience through collaboration and coordination care across providers (4 hospitals, 3 community providers, 93 GP practices, 5 social care organisations) with shared clinical practices and information. Aims of the 2) Decrease hospital usage including emergency admissions by pilot 30% and nursing home admissions by 10% for diabetics and frail The pilot elderly through better more proactive care. aspires to transform care 3) Reduce the cost of care for diabetics and frail elderly by 24% over 5 years. for 750,000 people across five boroughs 1) In the 1 st and 2 nd quarter of 2011/12 the practices involved in the ICP have experienced a 3.8% reduction on 2010/11 Non Elective Admissions for diabetic and elderly patient groups. 2) Primary care history and recurring activity of over 400,000 unique patients has been captured. 3) General Practices have consented over 1,800 patients into the Early results pilot and created over 1,600 integrated care plans. suggest 4) MDGs have held 65 integrated case conferences which have resulted in changes to care, medicine(s) prescribed, social care packages, and community, mental health and acute hospital support. 5 SOURCE: NWL ICP Operations Team
The ICP is governed by an Integrated Management Board (IMB) which is an association of all participating members Chair of Integrated Management Board General Acute Patient reps Community Local Mental Authorities Practice providers and third Health Health sector The legal documents signed by all the parties enable: • Creation of IMB and its processes and procedures • Assurance around funding flows • Establishment of an information governance framework, allowing for data sharing across the ICP Partners • Mutual accountability and collective decision making 6 SOURCE: NWL ICP Operations Team
Early feedback from clinicians has been positive (1/2) Today’s case conference was a good learning experience for me N=72 Neither agree nor disagree 4 64 32 Agree Strongly agree I feel satisfied with my personal contribution today 4 64 32 I believe the advice I received or gave today will help prevent an emergency admission 4 65 31 More than 90% of responses were Positive across the board This multi-disciplinary way of working has huge benefits for more joined up management and better relationships between all professionals. This will be very valuable for gathering ideas, and highlighting where there are issues/ glitches in the system, and will act as a foundation for more fundamental and system-wide change ~ General Practitioner Our multi-disciplinary discussion was a hugely valuable professional learning opportunity for me – I have already seen the benefits in the way I am treating my own patients, and am excited to see how this way of working will benefit the system overall ~ Community Matron SOURCE: NWL ICP Operations Team; Feedback from case conferences (clinicians & external observers) 7
Early feedback from clinicians has been positive (2/2) Common feedback Quotes ▪ Multi-disciplinary input seen as “Excellent joint learning opportunity – I really enjoyed benefitial for patients in most cases interacting with the other members of the MDGs and ▪ Good opportunity for joint learning gaining a better understanding of their roles” across disciplines, enabling more enjoyable and rewarding ways of Case “Our discussion highlighted working together confer- “Loved the opportunity to ▪ Multi-disciplinary way of working will areas that need further ences problem solve together on attention, like formal act as a foundation for system-wide where we can strengthen cognitive assessments for change by allowing clinicians to the system” the elderly” identify and problem solve around glitches in the system ▪ Collaboration in care planning seen “So useful to have access to a consultant for advice on the to be benefitial for patients and best care plan for my patients. Also great to be able to professionals alike discuss general local service issue with other GPs ▪ Standardised clinical protocols believed to have the potential to “Really good advice about where and who to refer to in significantly improve quality of care Care ▪ IT tool seen as useful in sharing future – this will enable us to streamline care and reduce planning the number of patients getting ‘lost’ in the system” patient data and tracking activity across settings ▪ Advice on referral pathways and “ IT tool enormously improved! I have managed very quickly available services valuable in to find pt, do consent and create care plan” streamlining care SOURCE: NWL ICP Operations Team; Feedback from case conferences (clinicians & external observers) 8
Modelling shows how admissions avoided at practice level can have a significant impact on the health system as a whole GP Practice Pilot Catchment Unit of measurement across pilot ▪ Avoid 7 ▪ Avoid 28 ▪ Avoid 1,753 ▪ Avoid 2,080 Reduction in admissions per admissions per admissions across admissions across emergency ~2,000 patients ~8,000 patients pilot of 506,000 catchment of admissions population 600,000 population ▪ Avoid 4,390 ▪ Avoid 15 ▪ Avoid 59 ▪ Avoid 3,700 Reduction in attendance across attendances per attendances per attendances A&E catchment of ~2,000 patients ~8,000 patients across pilot of attendances 600,000 population 506,000 population ▪ Saving of £50,000 ▪ Saving of ▪ Saving of £12.3m ▪ Saving of £14.6m Total reduction from emergency £200,000 from from emergency from emergency in emergency admissions and emergency admissions and admissions and care £1,250 from A&E admissions and £0.2m from A&E £0.4m from A&E £5,000 from A&E 9
1. The benefits of integrated care – learning from North West London 2. Developing the integrated care concept 3. Understanding the potential of integrated care 4. Realising the potential 10
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