Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Seamless pathways for longterm conditions: The Integrated Care Initiative Dr Peter Hammond Consultant Physician Clinical Director, Integrated Care What is a long-term condition? • A long term condition is any medical condition that cannot currently be cured but can be managed with the use of medication and/or other therapies. • This is in contrast to acute conditions which typically have a finite duration such as a respiratory infection, an inguinal hernia or a mild episode of depression. Royal College of General Practitioners Long-term conditions • 15 million people at least one LTC (2012) projected at 20 million by 2025 • Accounts for 70% of NHS expenditure • 68% OP and ED appointments; 77% of inpatient bed days • Person with 3 LTC: annual cost to health and social care £8000 on average NHS and Social Care LTC Model “The NHS, working with local authorities and the new health and wellbeing boards, needs to be much better at providing a service that appropriately supports these patients’ needs and helps them to manage their own conditions. Better management of their own conditions by patients themselves will mean fewer hospital visits and lower costs to the NHS overall, and more community-based care, including care delivered in people’s homes.” NHS Call to Action, July 2013 “Older people with long-term conditions want good primary care, community care and social care, joined up around them regardless of clinical categories or structural splits between healthcare on one hand and social care on the other. They want good out-of-hours services, so that their conditions can be managed in their own homes and prevented from deteriorating, and to make it possible to minimise upsetting, disruptive and expensive episodes in hospital. This is not the system we have.” Ready for Ageing? House of Lords select committee report 2012-13 What is integrated care? NHS Future Forum 2012 • Integration should be defined around the patient, not the system – outcomes, incentives and system rules (ie. competition and choice) need to be aligned accordingly. • Health and wellbeing boards should drive local integration – through a whole-population, strategic approach that addresses local priorities. • Local commissioners and providers should be given freedom and flexibility to ‘get on and do’ – through flexing payment flows and enabling planning over a longer term. Integrated Care means Person-Centred Co-ordinated Care National Voices: A Narrative for Personcentred Co-ordinated Care 2013 The House of Care “A seamless service” Self care and independent living Comprehensive Integrated Higher quality Affordable Community based care Hospital / Specialist care Wide-ranging health services, from supporting prevention and self-care, through support in the community, to specialist care. All health and social care services working closely together to provide one seamless service Better quality care, with more lives saved and more people returned to full health A service that is affordable in the years to come 14 Diabetes Care: an integrated care pilot Why Diabetes? • £725 million/year spent on diabetes medication: 8.4% total NHS drugs spend • £600 million extra is spent on in-patient care for people with diabetes • People with diabetes account for 15-20% patient bed days Why Diabetes? • Well-developed good quality primary and secondary care services, with active local diabetes network BUT • Working in “silos” – good working relationships but limited integration at all levels: – Patient focus – Information sharing – Knowledge-management Integrated model - strengths • Patient-centred – Meaningful consultation; Personal agendas • • • • • • Seamless patient movement through service Practice self-assessment Integrated patient record Integrated knowledge management Managed clinical network Partnership working as opposed to devolution; secondary care providing community-based services • Different funding arrangements Patient Pathway Referred back to GP practice GP to decide what level of care is required GP unable to provide care Two-way referral system TRIAGE at Single Point Access (SPA) at LTC Centre MDT Intermediate Care, including transitional and rapid access clinics: Education New Type 2 DAFNE Insulin Dose Adjustment Post Insulin Initiation CSII therapy Consultant / GPwSI DSN Dietician Podiatrist Psychologist Can refer to SPA for services not available in practice e.g. education, podiatry, retinal screening, weight management Secondary Care At Risk Foot Clinic DSN Podiatrist Consultant / GPwSI Patient with Diabetes GP services providing routine diabetes care A&E or Emergency GP Admission Single referral form to Weight Management Programme Treatment Pharmacy-Led Cardiovascular Risk Clinic Housebound Patients Residential &/or Nursing Home Housebound End of Life / Palliative Care Prison District Nurse / Community Matron reviews supported by DISC Team Inpatient Assessment & Management Patient Groups within OP services: Paediatrics Renal inc. dialysis pts Complex Patients CSII therapy Retinopathy treatment Joint Diabetic Foot Optimise Pre-op surg End of life patients Urgent OP Referral Access Foot Ulcers Gestational Pregnancy/Pre-conception complete Retinal Photography Service Evidence of Complications or Management not possible in Primary Care For MDT meeting review Referral to secondary care Primary Care / General Practice Diabetes Intermediate Specialist Community Team COMMUNICATION Secondary Care Equality of Access P GP practices Inc: Practice Nurses District Nurses Community Matrons Out of Hrs Service - Point of access - Triage & Assessment - Prevention - Screening - Risk Assessment - Public Health - Education - Self-management - POCT - N/H & R/H - Housebound Pts: Prisons Mental Health Learning Difficulties End of Life I Workplace Occupational Health School Nurses - Public Health - Prevention - Risk Assessment - Education - Awareness Pharmacies Enhanced Services - Prevention - Screening - POCT - BP assessment - Education Inc.Training on blood glucose monitoring - Empower patient through self-management e.g. troubleshooting BG meter issues - Risk Assessment - Referral to GP as necessary for Triage LTC Centre (Harrogate) Pilot Sites to cover rural population e.g. Ripon, B’bridge, The Dales, Skipton - Housebound Pts: Prisons Mental Health Learning Difficulties End of Life - Support of N/H & R/H - Retinal Photography - At Risk Foot - CV Risk Pharmacist Clinic - Education - Interm. Care team Clinic - Weight Management programme - Rapid Access Clinic S - Children - Transition Care - CSII Assessment and Initiation - InPt Diabetes Team - Dialysis Pts - Retinopathy Treatment - Joint Diabetic Foot Clinic - Pregnancy inc Gestational - Complex Pts - Optimise pre-op surgery - End of Life pts (through Macmillan Dales Unit) Code: Green – Primary Care Orange – Intermediate Care Children Complex LT conditions Gestational and pregnancy Inpatient Hospital Care CSII initiation and unstable patients Active Diabetic Foot Complications Pre-op surgical patients Dialysis patients End of Life patients Problem patients Unstable diabetes LT complications Stable CSII patients High risk foot assessment Structured education Retinal photography Housebound patients End of life patients Transition Clinic T1 – management of stable patients BD or Basal Bolus insulin initiation for T2 Insulin Regimen Changes Insulin Initiation – once daily T2 on Insulin Prevention Screening IGT T2 on diet or OADs Education Housebound Patients End of Life Patients Practice Level Management Practice Level 1 Practice Level 2 Practice Level 3 Practice Level 4 Red – Secondary Care LTC – pathways of care Pathways of care • • • • NYYPCT initiative Facilitated by Ernst and Young Stimulus to integrate telehealth Representation from PCT, secondary and primary care providers across NY • Consensus pathway to define practice across NY Diabetes Care Pathway: Adult Type 2 Diabetes Patient identified through primary or secondary care screening Patient presents with symptoms of diabetes Patient identified through opportunistic testing (history, high BP) Patient referred by Optician Blood glucose, HbA1c and urine tests Patient self-refers following blood glucose test at local pharmacy Consider alternative diagnosis, eg. classification of diabetes as genetic causes e.g. MODY, secondary causes, or Type 1 Patient is acutely unwell (possible Type 1 diagnosis) – refer urgently to acute hospital Diabetes confirmed, Type 2 suspected Are there any immediate indications for referral to secondary care? Yes Indications for referral Patient has complications Foot Cardiovasproblems cular Refer to joint diabetes and obstetrics clinic for all patients pregnant or considering pregnancy now or at a later stage Renal disease Visual impairment No Management of patient in primary care: Produce care plan and negotiate patient goals (including cholesterol, blood pressure and HbA1c targets) Introduce to local Diabetes UK group Standard referrals for all patients Offer exercise on prescription or other exercise opportunities / No advice Offer all patients full-length structured education course (DESMOND or equivalent) Refer all patients to retinal screening pathway Yes Offer all smokers cessation support Yes Would the patient benefit from a delay before commencing medication to allow a period of diet and lifestyle adjustment? GP/Practice Nurse reinforces education and supports patient in new diet and exercise regime for three months Can patient be discharged to primary care for initial diabetes management? No Women who are pregnant and a small proportion of patients who have unstable complications will be managed by specialist team, including receiving standard advice and referrals No Immediately begin oral drug therapy and titrate up alongside diet and lifestyle adjustment Yes Would the patient benefit from a delay before commencing medication to allow a period of diet and lifestyle adjustment? GP/Practice Nurse reinforces education and supports patient in new diet and exercise regime for three months No Immediately begin oral drug therapy and titrate up alongside diet and lifestyle adjustment Retest HbA1c after three months. If target not reached begin/increase drug therapy Introduce insulin as necessary Initiate insulin in primary care (refer patient to nominated GP surgery if not able to provide treatment in patient’s own surgery) Self-monitoring of blood glucose should be considered for patients where hypoglycaemia is a risk (see PCT guidelines) Refer to secondary care or alternative service where incretin or insulin therapy is required and cannot be initiated by primary care For patients with raised BMI consider use of incretin therapies (GLP-1 – see CG87) and seek specialist advice as to suitability Discharge to primary care where appropriate For patients who are unable to inject or monitor own blood sugars, Community Nursing service can provide support Primary care – Perform regular reviews and test HbA1c every 3-12 months depending on patient condition Give lifestyle and nutrition advice as part of review Review care plan and renegotiate as necessary Check for complications and frequency of hypoglycaemic epidodes Review medication including up-titration/withdrawal of drugs Is the patient adequately managing their diabetes, complications and comorbidities? Maintain process of annual care plan review throughout lifetime No Yes Go to glycaemic emergency pathway Yes Has this led to a glycaemic emergency? Indications for referral and treatment/support provided Patient has diabetic complications Foot problems Renal disease Cardiovascular Visual impairment Refer to relevant specialist e.g. Podiatrist, Opthalmologist for treatment of complications Patient is pregnant or considering pregnancy Refer to joint diabetes and obstetrics clinic Patient has inadequate control of diabetes, and/or change in lifestyle that for example leads to change in eating patterns or exercise levels Refer to specialist diabetes team or intermediate care clinic (e.g. Mowbray Sq) to support change to drug regimen. Consider referral for further education e.g. DESMOND Patient experiences frequent hypoglycaemic episodes or hypoglycaemia unawareness Refer to specialist diabetes team or intermediate care clinic (e.g. Mowbray Sq) to support change to drug regimen Patient has inadequate control due to poor compliance, anxiety or depression Refer to clinical psychologist/counselling service for psychological support (for both patient and carer where appropriate) Patient has comorbidity of COPD and/or heart failure that is adversely impacting their diabetes or vice versa Consider referral for telehealth monitoring Patient continues to have inadequate control despite optimisation of multiple treatment types Consider referral for telehealth monitoring Patient has inadequate control on insulin therapy Refer to specialist diabetes team for optimisation of insulin therapy (possible use of incretins). Consider continuous glucose monitoring No Locality diabetes care - progress • Successes – QoF – Intermediate clinics • MDT • Admission avoidance • Patient engagement • Challenges – Prescribing targets – Capacity • Education • Injectable therapy – Individualised therapy Implementation - challenges • Stakeholder engagement • Finances – ensure not a barrier to development • Staffing – ensure efficient use of human resources • Location – ensure adequately address access issues • Dissemination – models developed and lessons learned need to inform other service developments • Technology The Future Hospital Commission Hospitals on the edge? In September 2012, the RCP highlighted the challenges facing hospitals: •rising clinical demands (37% rise in emergency admissions, fewer beds) •changing needs (more older people, with multiple, complex conditions) •fragmented care (patients being moved around the system with little continuity) •out-of-hours care breakdown (higher mortality at weekends and fewer senior staff) •medical workforce crisis (increased workload, recruitment problems in emergency and general medicine) Future Hospital’s aim Identify a new way of designing and delivering hospital services that: •Comes to the patient •Is coordinated around patients’ needs (including for patients with multiple conditions) •Is organised over seven days •Reaches beyond hospital walls •Values patient experience as much as clinical outcome •Delivers clear lines of responsibility for patient care A new model of hospital care Medical Division - Covers all medical services and teams Remit from hospital into community Led by Chief of Medicine Acute Care Hub Part of Medical Division Covers assessment and initial management of acutely ill patients (focus: first 48 hours) Overseen by acute care coordinator Clinical Coordination Centre -Operational control centre for medical services -All data on patients – needs and real time monitoring -All data on capacity and resources New Model of Clinical Care • • • • • • • • • Hospital services that operate across the health economy Seven-day services in hospital Seven-day services in the community Continuity of care as the norm Stable medical teams in all acute and ward settings, focused on the whole care of the patient Focus on alternatives to acute admission and supporting patients to leave hospital Care delivered by specialist teams in community settings Holistic care of vulnerable patients Information is used to support care and measure success: Clinical records will be patient-focused Information will be held in a single electronic patient record Common record standards Information viewable in both the hospital and community Traditional Model Integrated health model Integrated care: the LGA* view • The concept of integrated care has developed as a response to fragmented delivery of health and social care services in some parts of the current health and care system. • The Better Care Fund (BCF) is one of a number of initiatives through which the integration of care and support will be achieved. *Local Government Association The challenge • Develop more flexible, efficient pathways of care across health and social care • Less reliance on condition-specific pathways of care • Be able to adapt care to the individual patient’s needs A Health and Social Care model? “The Patient Hub”