Active Health Management - NHS Confederation/media/Confederation/Files...Monitoring/ Coaching LTC...
Transcript of Active Health Management - NHS Confederation/media/Confederation/Files...Monitoring/ Coaching LTC...
02/02/2015
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New Ways of WorkingFfyrdd Newydd o Weithio
Chaired by: Stewart Greenwell ADSS Cymru/ADSS CymruCadeirydd:
Speakers: Linda Rees Telehealthcare Consultant, TunstallSiaradwyr: Ymgynghorydd Teleofal Ichyd, Tunstall
Robert Panou Development Manager, Bron Afon Community HousingRheolwr Datblygu, Cartrefi Cymunedol Bron Afon
Michelle Brewer Independent Living Service Manager, Melin HomesRheolwr Gwasanaeth Byw Annibynnol, Cartrefi Melin
Jonathan Davies Corporate Director, Sport WalesCyfarwyddwr Corfforaethol, Chwaraeon Cymru
Simon Jones Public Affairs Manager, Sport WalesRheolwr Meterion Cyhoeddus, Chwaraeon Cymru
@welshconfed#wnhsreality15
Active Health Management
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Healthcare in the future
Managing the healthcare of an aging population with “finite” budget, time and resources
Complex care needs, informed patients & higher expectations
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The traditional, passive approach initiated by the patient visit to the GP, is no longer affordable
Active Health Management will become the way healthcare will be done in the future
Active Health Management extends care programmes to include supported Self‐Management
Virtual clinics and remote monitoring extend the range of care facilities and eliminate travel & fixed appointment regimes for staff & patients
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Proportion of Population:
Healthy
Prevent
Delay
Manage
Complexity
Reablement
The Healthy Citizen Journey
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• Proactively supporting self‐management and focusing on a person’s confidence about looking after themselves is known to have a positive impact on clinical outcomes, maintaining wellness and reducing deterioration.
• Weight loss, COPD, Diabetes, hypertension management , CHF
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The Healthy Citizen Journey – Self Manage
Mary, 34 is overweight and on the verge of diabetes. She has been referred to the Guided Self management programme. Mary now has the tools to take ownership and manage her own health outcomes. Mary monitors her diet, activity, weight and medication.
The weight management
Programme is able to help
Mary keep on track
Mary’s weight reduces. Preventing her from potential of developing diabetes and other weight related illnesses
Mary is able to notice daily changes in her health and readings. Allowing her to adapt her lifestyle accordingly.
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• Adding a monitoring service to active health management gives the clinical team a more timely opportunity to intervene and support an individual to stay on track
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The Healthy Citizen Journey – Delay
Jim, 50 lives with hypertension. His clinical team monitor his condition using vital signs readings via the ICP software.
Following breeches of agreed personal parameters
and analysis of track and trend data Jim’s medication is altered to help delay exacerbation of his condition.
Community nursing teams utilise available resources to maximum capacity whilst always in touch with Jim’s condition.
Clinical input is within the home. Helping to avoid unplanned admissions and A&E visits
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• Management of complex chronic conditions or regular monitoring of elderly individuals in care homes can build confidence in a care team in managing individuals remotely –reducing hospital admissions and other expensive care interventions
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The Healthy Citizen Journey – Manage
Jo, 75. Has been diagnosed with chronic heart disease. Living in an extra care scheme with nursing support Jo is able to benefit from the community’s Telehealth support programme.
All visiting and in house health care professionals are well informed on Jo’s condition allowing timely and affective interventions.
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Reduced
Ambulance and out of hours calls are reduced through intelligent management of her condition.
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SelfManagement
Monitoring/Coaching LTC
Management
Pre-hospitalCondition
SupportedDischarge
Active Health Management within the Healthy Citizen Journey
Healthy &Well
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• The mobile Professional App that allows monitoring of multiple patients each using Tunstall mTrax.
• Key health and fitness indicators are available for each individual, sortable, colour coded, with drill‐down capabilities
• The mobile patient / personal App that enables personal tracking of key health parameters such as Body weight, blood pressure, heart rate, activity, sleep and more.
• Manual entry of data or automated eHealth sync from a wide range of health devices
Tunstall mPro Tunstall mTrax
• Tunstall service includes programme design, set up & staff training • Fees for cloud hosting and full system support• mPro app & mTrax for users to download onto smartphones or tablet on Android and iOS
Supported Self-Management
Tunstall Health CloudThe central, secured information repository of the system, designed to keep the mTrax and mPro applications in sync.
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System Tools
Adding new dimension to EHR/SCR
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Electronic Health Record / Social Care Record
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Delivering Programmes At Scale
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1. Identify Patients
Anyone with a smart phone or tablet can participate
2. Programme Referral
Individualised programmes with goals and related coaching
Email invite to mTrax user to sign up
3. Start to Self Manage
mTrax user follows routine providing vital signs and other data
Customisable interface with additional features & option to share data with carers, friends or family
5.Virtual Clinic
mPro user dashboards and data analytics facilitate support programmes
Patients who are doing well may not need to come to clinic
4.Informed Check
Data capture and trending for user decision making
Coaching & context specific information supports lifestyle choices
6. Progress Report
mTrax & mPro users review progress using the same data set
Self‐Management reports can be included in EHR
Health, Housing and Social Care‘In One Place’
Together we can make a difference
Robert Panou and Michelle Brewer
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Health, Housing and Social Care working together ‐ a new concept?
Key Policy Drivers
• Social Care and Wellbeing (Wales) Bill – enacted 1st
May 2014• Housing Bill 2014 • Health Homes, Healthy Lives, 2012• Simpson Report: Local, Regional, National – what is
appropriate at what level• Together for Health – setting out direction for NHS
in Wales, and a partnership approach• Williams Commission Report– Reforming Local
Government
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“ In the current Climate of cuts, austerity and higher demands on services, the only way we can hope to meet the future challenges of service delivery, and to help Welsh Government deliver its obligations, is through more innovation and better collaboration”
(Healthy Homes, Healthy Lives, Care and Repair Cymru 2012)
What is In One Place?
• A new model of collaboration between Health, SocialCare and Housing ‘In One Place’
• Supported by Aneurin Bevan Health Board, 5 LocalAuthorities, 8 Registered Social Landlords and theWelsh Government
• Aim is to work together to streamline the process of obtaining suitable, local accommodation for people with complex health and social care needs.
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In One Place ‐ 2 step approach ‐ now and in the future
Now ‐ We can look at what is available through the Housing Registers or existing/ void properties.
Future – We need to strategically plan for forthcoming need. What will the need be for your client groups in 12, 18, 24, 36 months time? The more forward planning we do , the more needs we meet.
Benefits to collaboration
• Supports the delivery of health, social care and housing strategies
• Timely provision
• Local provision
• Improvement in governance
• Appropriate provision
• Enables service users to have the same rights
• Cost Benefit
• Consistency of residency
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Overcoming barriers
• Health, Social Care and Housing – different worlds; different words
• Lack of needs analysis
• Timescales
• Legal and legislative
• Funding
• Communication
• Attitudes
In One Place Programme of Developments 15/16
• Torfaen 1 (3 service users) – Potential savings 150K• Torfaen 2 (6 service users) – potential savings 300K• Newport (8 Service users) – Potential savings 400k• Caerphilly (7 Service users) – potential savings 350K• Blaenau Gwent (3 service users) potential savings
150k• Monmouthshire (5 service users) – potential savings
250k• Many more in the pipeline………………
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In One Place In Action ………….
…………. Lion Court
• 4 units of accommodation were identified for inclusion in the IOP Programme
• 3 units for service users and 1 for the care provider
• A MDT was set up to include reps from Health, Social Care and Melin to collaboratively take the project forward
• Local Councillors and partner agencies consulted
• 3 service users identified• Care providers appointed and commissioned
through CHC/Social Care as previously done• Transition period started
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• Two service users identified from the Mental health division
• One has been transferred from a hospital ward and one from an out of county low secure setting
• 24 hour support is provided by liberty care • Nearly 3 months in and they have both settled in brilliantly to the accommodation and the community.
• In addition to the benefits to the service users there is currently an annual predicted saving of Approximately 100k on 2 units alone.
• Not always straightforward but collaboratively obstacles were overcome
Melin is more than just a social landlord:
• Long‐term investment in communities• Work in partnership to make a difference
• Tailor our services to meet residents’ needs
• Melin Works: offers our residents training and support to help them find work
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“I am thankful for places like this to live because I know it is my last chance to move forward with my life. I appreciate what everyone has done for me and the flat has given me the chance to move on”
Service User from Lion Court
Lasting thought ............True, effective collaboration has to be about relinquishing control and leaving competition at the front door.
“ Alone we can do so little;Together we can do so much”
‐ Helen Keller
Questions??
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Contact details
Email: [email protected]
Programme Manager ‐ Chris Edmunds : [email protected]
Programme officer – Joanne Lewis‐Jones: [email protected]
Programme Administrator – Beverley Anderson: [email protected]
Robert Panou, Development Manager, Bron Afon Community Housing: [email protected]
Michelle Brewer, Independent Living Service Manager, Melin Homes: [email protected]
Jonathan Davies
Corporate Director
Simon Jones
Public Affairs Manager
Halting the Tide of Inactivity
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http://youtu.be/eNvHHKHt-x0
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• Betsi Cadwaladr University Health Board (BCUHB) and Disability Sport Wales partnership, aiming to transform the relation between health and (disability) sport across North Wales.
• A formal pathway has been coproduced enabling disabled people to be signposted directly from health to physical activity /sport opportunities.
• Dedicated post to provide health professionals with information and link to sport development opportunities in the North Wales area.
• 522 BCUHB staff trained to date (January 2015) & 36 NERS Exercise Professionals
have attended training (all 6 North Wales local authorities)
• Over 200 formal signposts to physical activity (including sport) from Health
• Boccia is now being used as part of rehabilitation in the three Stroke
Rehabilitation Units across the region. Bringing sport into rehabilitation is helping
improve patient’s outcomes, confidence and enjoyment, providing a great
introduction to sport at an early stage prior to discharge.
• 1 elite athlete has been identified, signposted from Posture and Mobility
Services, going on to compete for Wales U15’s in wheelchair basketball.
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Thank you / DiolchTwitter: @sport_wales
www.sportwales.org.uk