Service Model Integrated Care: Havering

Briefing

Service Model Dr Ashok Deshpande

CD for Community Services, Havering CCG

• B&D- Rolled out 2010/11

• WF and Redbridge- Rolled out 2011/12

• QIPP Savings Projected on: 20% reduction of previous years baseline of hospital admissions-top ICD 10 codes

• Current performance: B&D and WF currently exceeding target and Redbridge is on trajectory

• Havering- Started in 2011/12 but with a different model to the other 3 Boroughs.

Integrated Case Management in ONEL

Integrated Case Management Model of Care

Identify Service User

Care Planning Meeting Care Plan

Care Delivery Care Plan Review

Ongoing Care

Onward Referral

Self Management

Fortnightly cluster meetings held. Attended by core team Meetings approximately 45 minutes. 2-3 new patients plus other existing patients discussed.

Team agrees action plan for each patient

Patient is provided with information on what to do in case of emergency Care plan shared with MDT and

discussed at next meeting. The MDT team reviews the care plan and agrees if other measures need to be put in place to prevent the admission. The team risk rates the patient and agrees a follow-up period.

Community Matrons undertake an assessment of the patient . Members of the MDT provides patient with the necessary care to prevent admission. Liaison officer follows through with patient and MDT to ensure service is provided.

Patient referred to supporting services in the community

Patient kept on the register for a period of 6 months for on-going care.

Health Analytics used to identify top 1% of patients at risk. Clinical judgement used to supplement the risk stratification tool.

4

What is Integrated Case Management? Integrated Case Management (ICM) is a model of

practice which aims to ensure that patients with complex health and social care needs receive the right care, in the right place, at the right time.

ICM is underpinned by a ‘team around the patient approach’, whereby identified providers across health and social care, collaborate together within a systematic framework to offer multi disciplinary, co-ordinated and quality care to vulnerable adults.

What are the benefits of the ICM model?

Improved quality of care

• Provides proactive care, closer to people’s homes, that improves clinical effectiveness and patient experience

• Removes frustrations of the patient journey that too often cause patients to fall into the gaps between services

• Prevents patients from having to repeat their story multiple times and means those delivering care to them know what is happening

Creates a richer professional experience

• Eliminates day-to-day frustrations from care delivery and multi professional liaison

• Delivers improved clinical reasoning – from didactic to dialectical decision-making

• Brings new mutual accountability to the patient pathway, not merely the episode of care

Financial efficiency

• Acknowledges that delivery of the right care in the right place can ensure financial efficiency via prevention of unnecessary interventions and procedures including avoidable attendance to A&E

What are the benefits of the ICM model?

Service Model ICM Teams

Service Description

The Havering Integrated Care (IC) team aim to deliver appropriate care to patients in the community to reduce avoidable hospital admissions and deliver a high quality service for high risk patients. There will be 6 clusters across Havering with a Community Matron and Integrated Care Liaison Officer allocated to each. The Integrated Case Management team comprises of:

GP Community Matron District Nurse Social Worker Care Liaison Officer Any other relevant staff for specific needs e.g. mental health team.

Patients who will benefit from this service are those that have been identified as high risk with complex needs (Working through the Top 1% at risk on Health Analytics gives this process more structure; any member of the IC team is also able to refer in to the service based on clinical/professional judgement).

Integrated Care Management Virtual Team

Service User

GP

Community Matron

Social Worker

District Nurse

Practice Nurse

Care Liaison Officer

Therapies

Acute care specialists

End of Life Mental health

Third Sector

Drug & Alcohol services

Service Model Identification of Service Users

Referral Criteria

18 years and over Registered with a GP in Havering Resident of Havering, Redbridge or Barking and Dagenham and registered with a GP in Havering Not requiring Emergency Care at time of referral Consensus from all IC team that the patient will benefit and can be case managed in the community.

Categories of patients adopted for Integrated Case Management Patients with one or more unstable or poorly managed / poorly understood LTC/EOL care needs Patients with a range of compounding problems e.g frail elderly, progressing disability, social, environmental or care issues. Exacerbation of chronic conditions including COPD, HF, diabetes

Patients unsuitable for Integrated Case Management o Substance abuse as sole diagnosis o Nursing home resident o Hospital admissions due to on going scheduled treatment (i.e. chemotherapy / cancer) o Mental Health as sole diagnosis.

Identification of Service User

Health Analytics

• Top 1% risk segment

Clinical •Clinical opinion service user at high risk of hospital admission

Referral criteria once identified: • 18 years and over •Registered with a GP in Havering •Resident of Havering (Redbridge, Barking and Dagenham residents may also be accepted) •Not requiring emergency care •Virtual Integrated Care Management Team have consensus that the person referred will benefit from integrated care management and can be case managed in the community.

It would seem intuitive that clinicians such as doctors and nurses, who often know their patients extremely well, would be best placed to make predictions about which individuals are at highest risk of unplanned hospital admission.

There are three important theoretical reasons why predictive models may be preferable to predictions made by clinicians.

1. Predictive models are able to screen whole populations on a regular and repeated basis. This is simply not feasible for a single professional to do.

2. Clinicians are unable to make predictions about patients who are not known to them. In contrast, predictive models can take account of patients’ contacts with any part of the health care system, as well as other predictive factors such as deprivation and the propensity of different hospitals to admit patients.

3. Clinicians – like all human beings – are susceptible to a whole range of different cognitive biases that make it difficult to translate observation at an individual level into reliable estimations across a population.

The bottom line is that predictive models will be more accurate than clinical opinion (Curry and others, 2005). Indeed, in a recent study, the predictions made by doctors, nurses and case managers were found to be statistically no different from chance (Allaudeen and others, 2011).

Why Risk Stratification?

A &E Flags AE visit - Investigation X-ray – last 90 to 180 days AE visit - Arrived by ambulance - last 30 to 90 days AE visit - Disposal to Specialist - last 0 to 30 days AE visit - Medical DX (non-Injury) - last 30 to 90 days AE visit - Medical DX (non-Injury) - last 365 to 730 days AE visit - last 180 to 365 days 2 AE visits - last 180 to 365 days 3+ AE visits - last 180 to 365 days GP Flags COPD (LTC) Psychoactive substance misuse disorder Psychotic disorder 1 (from 8) LTC 2+ (from 8) LTC 7+ distinct disorders (GP data) 1-4 unique drugs In any month - last 0 to 90 days 5-9 unique drugs in any month -last 0 to 90 days 10+ unique drugs In any month - last 0 to 90 days Smoking status "yes" last 0-365 days multiplied by Asthma (LTC) Smoker A combination of: Bronchodilator preparations (last 0 to 90 days) Bronchodilator preparations (last 30 to 90 days) Bronchodilator preparations (last 90 to 180 days) Bronchodilator preparations (last 180 to 365 days)

Inpatient Flags

Emergency admission for Impactable condition (HRG code) - last 30 to 90 days

Emergency admission for Impactable condition (HRG code) - last 90 to 180 days

Emergency admission for Impactable condition (HRG code) - last 180 to 365 days

1+ Emergency admission - last 0 to 30 days

1 Emergency admission - last 30 to 90 days

2+ Emergency admissions - last 30 to 90 days

Emergency admission - last 90 to 180 days

2+ Emergency admissions - last 90 to 180 days

1 Emergency admission - last 180 to 365 days

2 Emergency admissions - last 180 to 365 days

3+ Emergency admissions - last 180 to 365 days

1 Emergency admission ~ last 365 to 730 days

2 Emergency admissions - last 365 to 730 days

3+ Emergency admissions - last 365 to 730 days

Average number of episodes per Emergency admissions > 3

Expected ratio for rate of re hospitalisation for hospital of last admission

Outpatient Flags 1 out-patient speciality visit - last 0 to 30 days 2 out-patient specialty visits - last 0 to 30 days 3+ out-patient specialty visits - last 0 to 30 days 1 out-patient specialty visit - last 30 to 90 days 2 out-patient specialty visit - last 30 to 90 days 3+ out-patient specialty visit - last 30 to 90 days 5 out-patient specialty visits - last 365 to 730 days 6-10 out-patient specialty visits - last 365 to 730 days 1+ out-patient specialty visits - last 365 to 730 days OP visit - Source of referral not an Acc & Emergency - last 0 to 30 days OP visit - Source of referral not an Acc & Emergency - last 30 to 90 days

Health Analytics has in built the Combined Model from the Kings Fund. The Combined Predictive Model identifies 77 different flags from patient information to calculate a risk score . These flags are:

How is the Risk Score Calculated?

Service Model Information Sharing and Consent

As part if the implementation plan for Integrated Case Management partners will be required to sign an Information Sharing Agreement prior to roll out in their cluster. This will enable partners of ICM to effectively share information about ICM patients and co-ordinate their care.

Partners to the ICM information sharing agreement will be as follows: - The patient’s GP - Adult social care - North East London Community Services - Whipps Cross University Hospital Trust - Barking, Havering & Redbridge University Trust - London Ambulance Service - Partnership of East London Co-operatives (PELC) Ltd - NHS Outer North East London

Patients will be required to consent to being part of the ICM Service. Explicit patient consent is required due to the range of partners involved in ICM and the potential sharing of sensitive data, particularly in relation to social care. Specific ICM Consent Forms have been developed for this purpose.

Health Analytics will be used to effectively share the patients holistic care plan with ICM providers via role based access. GP practices will be required to read code patients in order to facilitate access to the care plan by broader ICM partners

Information Sharing and Consent

Service Model ICM Care Planning Meetings

Care planning meetings will happen at the GP surgery every fortnight. Discuss between 2-5 new high risk patients at each of the meetings Care plan is developed and actions identified for relevant team members (recorded by care liaison officer) At the following meeting the team will feed back any progress with the patient When it is deemed necessary and the person no longer needs such high level intervention they will be moved onto an ‘inactive list’ which means they will be reviewed after 3-6 months but can be stepped back up into the meetings if necessary.

Care Planning Meetings

Summary of key aspects Referral Process/Meeting Cycle

Identify Patient Obtain verbal consent and complete verbal consent form. Send contact form and verbal consent to IC Liaison Officer (2-3 days prior to meeting) Patient to be discussed at the next Case review meeting (held every two weeks) IC liaison officer to provide administrative support; agenda, meeting notes and care plans, onward referral to specialist services etc. Designated member/s of IC team to assess patient, obtain written consent and feed back at next meeting.

Week 1: Coordination week

• Coordination tasks • No Case conferences

Week 2: Care Planning week

• Care Planning

Meetings to be held in this week

Fortnightly cycle of Case conferences allows for:

• Annual leave cover • Single time slot for Care Liaison officer to meet with CM to identify and screen service users • Allows time for streamlined Care conference slots

Service Model ICM Care Plan

• A specific template for the ICM care plan template has been developed in partnership with all ICM providers.

• This template is now available for use on Health Analytics

• Once the Integrated Case Liaison Officers have been provided access to the patients details on Health Analytics by the GP practice (via completing a simple read code form), the ICLO’s will then input care plan onto Health Analytics and ensure this is updated following review at the ICM Case

ICM Care Plan

ICM Care Plan View – Health Analytics

Service Model ICM Havering: Clinical Delivery Groups

Proposed ICM Clinical Delivery Groups

6

6

6

6 6 6 6

5 5

5 5

5 5

5

4 4 4

4 4

3 3

3 3

2

2

2

2 2

1 1 1

1

1 1

1 4 F82055

Y02973 2 F82671

6

6 4

2

3

4

Top 1% List Size #

Practices Cluster 1 738 47,684 9 Cluster 2 805 45,700 10 Cluster 3 582 38,646 5 Cluster 4 733 47,089 10 Cluster 5 519 37,230 9 Cluster 6 511 31,425 9

Summary of Clinical Delivery Groups

CDG Practice Name Address Code Top 1% List Size GP 1 SAINI Lynwood Medical Centre F82030 214 10,025 Dr GS Saini 1 JOSEPH Dr Joseph F82639 21 2,795 Dr P Joseph 1 MAHMOOD Dr Mahmood F82020 62 3,789 Dr M Mahmood 1 GUPTA Dr Gupta F82610 26 2,976 Dr NK Gupta 1 NORTH STREET North Street Medical Care F82009 189 12,888 Dr Burack 1 HASKELL Chadwell Heath Health Centre (Dr Haskell) F82052 36 2,343 Dr SJ Haskell 1 CHASE CROSS M/C Dr Kulendran F82630 53 4,148 Dr S Kulendran 1 A PATEL Chadwell Heath Health Centre (Dr A Patel) F82686 24 2,437 Dr AN Patel 1 HAMILTON-SMITH Chadwell Heath Health Centre (Dr Hamilton-Smith) F82019 113 6,283 Dr JA Hamilton-Smith

738 47,684

CDG Practice Name Address Code Top 1% List Size GP 2 PRASAD Dr Prasad F82671 65 2,605 Dr J Prasad 2 HAROLD HILL H/C Harold Hill Health Centre (Dr Jabbar) F82670 25 2,211 Dr A Jabbar 2 HAROLD HILL H/C Harold Hill Health Centre (Dr Kuchhai) F82014 132 6,555 Dr NA Kuchhai 2 HAROLD HILL H/C Harold Hill Health Centre (Dr Kakad) F82016 106 6,024 Dr J Kakad 2 RABINDRA Robins Surgery Y00312 42 3,721 Dr K Rabindra 2 INGREBOURNE M/C Ingrebourne Medical Centre F82648 63 2,381 Dr A Kaw 2 FELDMAN Petersfield Surgery F82010 114 5,847 Dr M Feldman 2 MCDONALD Dr McDonald F82007 185 12,960 Dr H McDonald 2 HURLEY GROUP Harold Wood Polyclinic Y02973 12 No Data 2 CHOUDHURY Dr Chowdhury F82045 61 3,396 Dr RS Chowdhury

805 45,700

Proposed ICM Clinical Delivery Groups

These proposed clinical delivery groups involve four small changes to the clusters that the Community Matrons currently work in. These changes are necessary to ensure the manageable running of the Integrated Care Project; (i.e. that no one cluster has an unmanageable number of practices). This will affect the named Matron that four practices are currently working with. Cluster 3 will be covered by the Lead Matron and is the smallest cluster which will allow time for management responsibility for the Community Matrons and ICLOs as well as covering these five practices.

CDG Practice Name Address Code Top 1% List Size GP 4 KUKATHASON The Modern Medical Centre F82638 52 3,264 Dr P Kukathasan 4 POOLAGANATHAN Rush Green Medical Centre F82039 39 3,664 Dr S Poologanathan 4 UBEROY Dr Uberoy F82646 94 5,199 Dr S Uberoy 4 TOTAL HEALTHCARE Total Healthcare F82055 37 3,058 Dr A Tran 4 BLAND The Medical Centre F82675 77 3,966 Dr TC Bland 4 P M PATEL Dr PM Patel F82609 78 4,188 Dr PM Patel 4 GILLETT-WLLER The Surgery (Dr Gillett-Waller) F82641 19 1,891 Dr QHA Gillett-Waller

4 RAHMAN Dr Rahman F82666 38 2,796 Dr MM Rahman & Dr T Rahman

4 MAYLANDS M/C Maylands Health Care

F82008 242 14,036

Drs Brandman, Kendall, Carruthers, Rao, Aggarwal, Shridhar.

4 BEHESHTI Rush Green Medical Centre F82031 57 5,027 Dr B Beheshti 733 47,089

CDG Practice Name Address Code Top 1% List Size GP 5 WOOD LANE M/C Wood Lane Surgery F82028 99 4,711 Dr AR Deshpande 5 JAISWAL Dr Jaiswal F82618 1 1,981 Dr AK Jaiswal 5 ROSEWOOD Rosewood Medical Centre F82022 177 10,787 Dr HM Vivers 5 SUBRAMANIAN Dr Subramanian F82619 19 2,148 Dr K Subramanian 5 WANI Dr Wani F82744 26 2,228 Dr MA Wani 5 BERWICK ROAD Berwick Surgery F82649 63 5,067 Dr R M Adur 5 JAWAD Dr Jawad F82607 37 2,287 Dr AKS Jawad 5 HUSSAIN Rainham Health Centre Y00183 19 1,730 Dr HH Hussain 5 S M SUBRAMANAM South Hornchurch Health Centre F82614 29 2,131 Dr S Subramaniam 5 ABDULLAH Rainham Health Centre F82627 49 4,160 Dr ARM Abdullah

519 37,230

CDG Practice Name Address Code Top 1% List Size GP 6 HAIDER Haiderian Medical Centre F82002 76 4,391 Dr S S Haider 6 DAHS Dr Dahs & Partners F82006 157 8,390 Dr C Dahs 6 KWAN Dr Kwan F82608 28 1,882 Dr D Kwan 6 O’MOORE The Surgery (Dr OMoore) F82624 44 3,000 Dr JCF OMoore 6 CHAKRAVARTY Dr Chakravarty F82657 36 2,199 Dr P Chakravarty 6 BAIG Dr Baig F82053 32 3,398 Dr S S Baig 6 CHOPRA Dr Chopra F82643 25 1,983 Dr Chopra 6 SUDHA Cranham Health Centre F82674 63 3,283 Dr IK Sudha 6 V PATEL The Surgery (Dr V Patel) F82033 50 2,899 Dr VM Patel

511 31,425

Proposed ICM Clinical Delivery Groups CDG Practice Name Address Code Top 1% List Size GP

3 MAWNEY M/C Mawney Medical Centre F82011 169 9,064 Dr DM Hamilton 3 WESTERN ROAD Western Road Medical Centre F82013 228 13,670 Dr DJ Bass 3 MARKS Dr Marks F82663 27 2,693 Dr CTC Marks 3 FLASZ Cosyhaven (Cecil Avenue) F82653 10 3,264 Dr M H Flasz

3 NEW MEDICAL CENTRE The New Medical Centre F82021 148 9,955 Dr M Edison

582 38,646

Service Model ICM Havering: Next Steps

Immediate Next Steps

• Phased roll out by Clinical Delivery Group (CDG)

• Roll out will begin with Dr Deshpande’s CDG (5) as Clinical Lead

• Relationship Managers will be visiting each practice in Havering to discuss the model in greater detail • Each practice in Havering will receive follow up visits prior to roll out within each CDG • The Caldicott guardian for each practice will be required to sign the Information Sharing agreement and protocol (to be signed by all stakeholders sharing patient information)