Integrating Care for Neurology Dr Mo Ali Clinical Director Whole - PowerPoint PPT Presentation

Integrating Care for Neurology Dr Mo Ali Clinical Director Whole System Integrated Care Neuroscience Strategic Leadership Group Integrated Care Programme

Overview • Initial journey • Implementation • Next steps • Learning lessons Integrated Care Programme

Initial Journey Integrated Care Programme

1 st Meeting: Definitions • <65 who are employed (no support and can spiral down) 1. • MS and MS with relapse Patient • Exclude Clinical Isolated Syndrome (CIS) Registry • Relapsing – remitting (and secondary progressive), primary progressive 2. Risk • Focus on just relapse • Stratification Use of disease modifying drugs • 3. Care Post – diagnosis: need continuity AND rapid access; potential use of personal budgets • Community package of care based on rehab and drug treatment in the community Pathways • Provide “hub of continuity” and within “turbulence create stability” based on anticipatory care plans • Initial care plan in secondary care 4. Work • Subsequent in primary care with access to a hub site • Activate care plan for quick access Planning • Use 111 5. Care • As much as possible in the community • Delivery Initiation only in hospital and monitoring in the community • Review at a large enough level to offer support at secondary care level (not Queens Square) 6. Case • Work through the numbers to establish right size Conferencing • Web based “online clinics” similar to neurolink  7.Performance • HES data (possibly risk strat too); UTIs, falls, respiratory infections, pain management, skin management  Review • Social indiicators: level of care (current changes to criteria from 50m down to 20m unrealistic if relapse – impact on DLA, care funding)  • Employment (905 within 10 years are not working) Initial Journey Integrated Care Programme

2 nd Meeting: Expansion • Defined as those diagnosed with MS up to 160/100k, NWL = 3,520 (0.16%), 440/CCG area 1. Patient Registry • Consider medical, psychological and social components 2. Risk Stratification • Last relapse 1. Asymptomatic 3. Symptom relapse : a. Infection exacerbation • Worsening symptoms 2. Symptoms: maintenance b. True relapse • New symptoms Emerging view Confined to bed or wheelchair Death Walks with aid (<5 yards) Walks unaided (≥330 -550 yards) Fully ambulatory Highest Relapses Highest Relapses Initial Journey Integrated Care Programme

1. MS Society have SUS 3 rd meeting: Focus 2. Harrow as a focus • Defined as those diagnosed with MS up to 160/100k, NWL = 3,520 (0.16%), 440/CCG area 1. Patient Registry • Consider medical, psychological and social components 2. Risk Stratification • Assume gradual progression through relapse Background Very High Risk (0.5%) = 18 • Trigger of care plan = relapse High risk (0.5-5%) = 158 • 85% Relapsing – remitting = 2,992 (50% secondary progressive = 1,496) Moderate risk (5-20%) = 528 • 10% primary progressive = 352 Low risk (20-50%) = 1056 Very low risk (50-100%) = 1,760 • 5% progressive relapsing = 176 Initial data set 1. Self – reported ‘I’ 2. SUS • Hospital, MH, practice, LA screened Very High Risk (0.5%) • 3. MS specific (?) Progressive Medical Potential Model • >1 relapse High risk (0.5-5%) • Motor • 3 axis of need triangulation • Sensory Social Psychological • Both Moderate risk (5-20%) • Infection • …. Low risk (20-50%) MS budget (NWL) Each patient = £19,726 › Equipment £5,966,753.89 Very low risk (50-100%) › Services £39,731,770.08 Patient 3 Axis Stratification Community Ward View › Medication £23,738,749.16 › Costs not included £255,309.03 › Overall MS budget £69,437,273.13 Initial Journey Integrated Care Programme

Choosing Harrow • Harrow: GPs, 3 rd sector, community and 3 acutes (!) • Move from fragmented to integrated delivery for patients • Consider steroids in the community model (oral) • Pick one area to pilot • Harrow: max. 368 (Margaret: 200-250 cases); 8 practices with >9 MS • 35 GP practices total, MS Therapy centre, Community Nurse • Northwick Park linked to NHNN • Central Mid linked to Imperial (Charing X/St Marys) • Use ICP infrastructure: online communication, meetings and 111 Initial Journey Integrated Care Programme

Historic Model of MS in Harrow • 35 GP practices • 1 community provider • 250+ patients • 1 MS nurse • 3 acute trusts • 1 MS Therapy Service • GP suspects and refers OR A&E Existing • Investigations Northwick or Central Middlesex Reporting in • Diagnosed at NHNN or Imperial and started on treatment 1. …. 2. …. • Community nurse (Ealing) at NPH supported by another trust • Access through assessment and remote treatment • Established diagnosis: care plan by GP practice 111 • Care plan linked to 111 and UCC/A&E across NWL Pilot Model • Acute access requires initiation of patients rescue therapy Care Plan or infection exclusion by primary care then involve nurse 1… 2.. • Referral to nurse for assessment and consider steroids • (?)Steroids in the community • Referral made to secondary care Initial Journey Integrated Care Programme

Implementation Integrated Care Programme

Existing case load • Direct access (nurse/consultant) • MDG partners (MH,SS, …) • 8 practices with >9 patients • Consider MDG frequency • Care coordinators • Need to upskills ! ! 8 practices with >9 patients ! RNOH • Bacon Lane Surgery = 10 Uxbridge Road ! Edgware 26 WIC • Elliot Hall Surgery = 9 ! Honeypot Lane 12 27 • Enderley Road = 14 11 High Road 37 Belmont 22 Circle 23 Uxbridge Road 21 27 2425 13 35 36 Kenton Lane • St Peters Medical = 9 33 34 10 9 George V Avenue 14 28 32 Harrow View • Northwick Surgery = 10 Christchurch Avenue 20 29 17 31 16 18 30 Pinner Road • The Pinn Medical Centre = 17 ! 15 19 ! Kenton Road ! ! 3 NPH ! • The Ridgeway surgery = 10 7 8 Watford Road 5 6 • The Stanmore Medical Centre = 11 2 3 4 1 Northolt Road Alexandra Avenue Implementation Integrated Care Programme

MS Model in a Slide • Hospital diagnosis Patient initial diagnosis in hospital (NHNN Current Model or Imperial) and treatment started • Review in community Review in community with secondary • Relapse care support at Northwick assessment in community or hospital setting Relapse assessment with return to originating hospital, no GP involvement MS Registry Case management Create registry at outset New Model Ongoing reviews Review risk, HSCC & GP Review population HSCC, GP + MS nurse Create MS Care Plan, give urine dipstick and script Set baseline for activity Regular review throughout Integrated MS with a starting score year Pathway Patient Level Multi-provider input BIRT 2 Practice Level MDG is the learning set Video-Conf Provider Level 111 Implementation Integrated Care Programme

MS Multi-Disciplinary Group (MDG) Pilots Listening • 3 meetings: • First meeting • GPs exciting, new • Second, • Social Worker, 3 rd Sector group, Psychiatrist similar pattern • Neurology consultant, Neurology Specialist Nurse • Third, • Community MS Nurse exhausted cases • Approx 18 patients reviewed in detail • Defined learning needs Soft Measures • Failures – • Exhausted reviews and looking to move to PD/Epilepsy trainee role • Mobile numbers • Break to complete education material before next steps • Patient transfer to GP Implementation Integrated Care Programme

Next Steps Integrated Care Programme

Whole Systems Integrated Care NWL = Focus of 15/16 “Shadow” “Shadow plus” Real budget with low risk Full risk sharing Focus on planning, Focus on governance and Focus on execution and Focus on execution with implementation and capability-building finances full ACP financial outcomes responsibility • Commissioner • Performance • Joint commissioning • Systems consolidated to Commissioners expectations for outcomes management systems responsibilities and commission at scale for are aligned and have been and capabilities are in processes are clearly population groups clearly communicated to place defined, and capabilities providers exist to meet them • Model of care plan is • Performance • Governance processes • Strong financial and robust and affordable management systems allocate funds effectively performance Providers • Implementation plans have and capabilities are in and hold partners management capabilities place to manage delivery accountable used to manage risk and been clearly • Continuous improvement • Procurement capabilities innovate model of care communicated and enacted and learning systems in place established • Model of care is aligned to • Organisations are ready • ACP meets procurement • Commissioner and System expected outcomes to change requirements provider incentives are • Plans are person-centred aligned to deliver highest quality of care at best and co-produced value for money Full assurance checkpoint Forward-looking assessment to evaluate Incremental checks required as the ACP to assess risk readiness or limitations adds population groups or functions management capabilities Next Steps Integrated Care Programme