Long Term Conditions - enherts-tr.nhs.uk · PDF file Back to joined up care Health...
Transcript of Long Term Conditions - enherts-tr.nhs.uk · PDF file Back to joined up care Health...
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Long TermConditions
Martin McShaneDirector – Domain2Enhancing the quality of life for peoplewith long term conditions
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The challengesNumber of Conditions1 % self reporting
1 30%2 13%
3+ 10%
The 15 million people in England with long term conditionshave the greatest healthcare needs of the population
(50% of all GP appointments and 70% of all bed days)and their treatment and care absorbs 70% of NHS and
social care budgets in England
1. The percentage of people aged 18 and over self-reporting experiencing long-term conditions in the GP Patient Survey
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Financial and population ‘gearing’
20/09/2014
Primary£200(6.5k)
Community & MH£500
Specialist£300
Acute£1000(330k)
Social CarePublic Health
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GP Specialist
1990
Specialist
2014
CAREGAP
Activity
Complexity
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Geology – strata - stratification
Multiple
Single
Preventing
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Intervention - stratification
Individualised
Standardised
Proactive advice
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CPM / PARR Tool for Systematic Risk Profiling to identify risk
Top 0.5%Community Matron /Virtual Ward as part ofMultidisciplinary Team(CommunityGeriatrician, GP, SocialCare, Therapists, Rehab,Domiciliary )
Care Planning andindividual personalisedcare plan
Disease Specialist Inputwhere required fromspecialist communityteams ( COPD, Diabetes)
Telehealth and Tele CarePsychological Support
Planned hospitaladmission , proactive inreach and facilitateddischarge where needed
0.6-5%Intensive disease / casemanagement byspecialist teams as partof the MDT
Telehealth / Telecare
Community SpecialistServices and clinics withMDT support
Care Planning andindividual personalisedcare plan
Planned HospitalAdmission for those whoneed it and facilitateddischarge viaintermediate care toreduce LOS
6-20%Proactive Disease Managementby General Practice supportedby specialist communityservices and teams
Care Planning and individualisedCare plan
Support to Self Manage
Education Programmes
Annual Review
Specialist Medication reviews
Anticipatory Care
Remote monitoring via tele healthwhere appropriate
Patients step up and down as risk profile changes
21% - 100%Proactive Self Care Supportand Management in PrimaryCare
Risk score recorded andreviewed annually
Active Case Finding
Disease Register
Accurate diagnosis
Information Prescriptions
Care Planning
Education relevant topatients needs
Disease prevention andHealth promotion
HIGH RISK / ComplexityLow RISK / ComplexitySmoking Cessation, Health Promotion and Self Care
Admissions Avoidance
Public Health
PopulationwidePrevention
Diseaseawarenesscampaigns
Socialmarketing
Education
Healthpromotion
Schools
Workforce Development, Training and Education
Co-ordinated Social Care
Newark and Sherwood Integrated Model of Care for Long Term Conditions
Special Patient Notes / 24/7 Access to specialist support
Personal Care Navigator / Named Lead
1
2
3
4
Level
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Population system approachLTC Framework:
• Empowered patient and carers• Professional collaboration• Best Practice (clinical and organisational)• Commissioning
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The House of Care
Organisational and clinical supportingprocesses
Engaged,informed
individualsand carers
Health andcare
professionalscommitted topartnership
working
Commissioning
Person-centredcoordinated care
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The House of Care - Person centred, coordinatedcare at three levels:
National:What can nationalorganisations and policymakers can do to enableconstruction of the Houseof Care at the next twolevels.
Local:How local health economiesensure that the House ofCare involves a wholesystem approach, including‘more than medicine’ offers
Personal:How the House of Care givesprofessionals on the front linea framework for what theyneed to do for patients andask local commissioners tosecure for them
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“Yes, but what has NHS England everdone for us?”
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http://www.england.nhs.uk/house-of-care/
Resources1. Toolkit2. Dashboard3. Infographic4. Improvement programme
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Health and careprofessionalscommitted topartnership
working
Engaged,informed
individuals andcarers
Commissioning
• Joined up care• Culture• Workforce• Technology• Care Co-ordination• Care Planning
• Information and technology• Care Planning• Safety and Experience
• Self management• Information and
Technology• Group and peer
support• Care Planning• Carers
• Service User and Public Involvement• Contracting and procurement
• Needs Assessment and Planning• Joint commissioning of services• Metrics and Evaluation
• Care Planning• Tools and levers
Build my ownhouse
Click on the links for more information abouteach component and use this to build your own
house
• Guidelines, evidence and nationalaudits
• Care Delivery
Organisational and supporting processes
Person-centredcoordinated care
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Joined-up carePeople living with long term conditions say that they would like careplanned with people who work together to understand them and theircarer(s), put them in control, co-ordinate and deliver services to achieveoutcomes.Ensuring care is designed and delivered around the needs of theindividual is particularly important for people with complex care needs. Back to house
Interdisciplinary workingProfessionals from different
organisations across health and socialcare and the voluntary sector working
closely together ensuring that care feelscoordinated to people living with long
term conditions and their carers.
Key Components• Single point of contact• Multi disciplinary team working• Professionals talk to each other• Services quick and responsive people
are promoted to stay independent andactive
• Care developed around the individualand not the system
Care Transition
Ensuring a seamless transition forpeople with long term conditionsbetween different care settings.
Key Components• Transition following discharge from
hospital• Transition between health and social
care• Transition related to changes in long
term care needs• Transition from children's to adult
services.
Health andcare
professionalscommitted topartnership
working
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Interdisciplinary Working
ResourcesIntegrated care for patients and populations: Improving outcomes by working together - Areport to the Department of Health and the NHS Future Forum, The Kings Fundhttp://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together
Integrated Care and Support Pioneers programme, NHS IQhttp://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions/integrated-care.aspx
Integrated Care – Better Care Fund – Local Government Associationhttp://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE
Integrated care value case toolkithttp://www.local.gov.uk/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4060433/ARTICLE
ICASE - Integrated Care Support and Exchangehttp://www.icase.org.uk/pg/dashboard
Kings Fund Integrated care: making it happenhttp://www.kingsfund.org.uk/projects/integrated-care-making-it-happen
Year of care, NHS Improving Qualityhttp://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/year-of-care.aspx
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Health andcare
professionalscommitted topartnership
working
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The soft stuff…is the hard stuff
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Mindsetsand beliefs
Values
Individualbehaviours
SOURCE: Scott Keller and Colin Price, ‘Performance and Health: An evidence-based approach to transformingyour organisation’, 2010.
Needs(met or unmet)
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Care plan vs Care Planning
A care plan is primarily focused on diseasemanagement; whereas in care planning the focusis on person management
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Care Planning
20/09/2014
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Care & Support Planning
“I” statements from National VoicesI work with my team to agree a care and support plan.I know what is in my care and support planI know what to do if things change or go wrong.I have as much control of planning my care and support as I want.I can decide the kind of support I need and how to receive it.My care plan is clearly entered on my record.I have regular reviews of my care and treatment, and of my care andsupport plan.I have regular, comprehensive reviews of my medicines.When something is planned, it happens.I can plan ahead and stay in control in emergencies.I have systems in place to get help at an early stage to avoid a crisis.
(http://www.england.nhs.uk/wp-content/uploads/2013/05/nv-narrative-cc.pdf)
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Person centredcoordinated care“My care is planned with people whowork together to understand me and mycarer(s), put me in control, co-ordinateand deliver services to achieve my bestoutcomes”
Communication
Information
Decision-makingCare planningTransitions
Mygoals/outcomes
Emergencies
Goal
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CommunityCare Primary Care
University/SpecialistFacilities
Social Care
GeneralHospital
ICare
The Future: 2014-2019