Creating person centred approaches to long-term condition ... · Maisy’s stepfather was an...
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CREATING PERSON CENTRED APPROACHES TO LONG-TERM CONDITION MANAGEMENT… OUR MAISY STORY DR NITI PALL CHAIR PHD CIC
Transcript of Creating person centred approaches to long-term condition ... · Maisy’s stepfather was an...
CREATING PERSON CENTRED APPROACHES TO LONG-TERM CONDITION MANAGEMENT…
OUR MAISY STORY
DR NITI PALL CHAIR PHD CIC
0-16 •Maisy was born in Birmingham in 1958. She never knew her father as he left her mother when she was 2 years old. Her mother married later in life after several abusive partners. Maisy’s stepfather was an alcoholic and often violent.
17 - 30 •Maisy left home at 17 years and had little contact with her mother until her stepfather died 8 years ago. Her mother now has dementia. She has to care for her as her brothers don’t help out. Maisy herself married young and had her first child at 18 years; then 3 more in quick succession.
31-45 •She has worked in a factory since her youngest child was 5 years. She was made redundant twice and has not been able to find work for the last 3 years. She lives in council accommodation on an estate where there are issues with anti social behavior by youths. Several times she has been targeted by them. They have shouted abuse directly at her and through her letter box at night.
46-60
•She has become very anxious and withdrawn. She doesn’t sleep well. She has debt from costs of fuel, food and helping out her children. Although still married, she and her husband have a very poor relationship. He has been out of work since losing his HGV licence. He has had 2 heart attacks and is 64 years. They don’t talk and he doesn’t help with the house, her mother or her 3 grandchildren. They sleep in separate rooms.
60+
•Maisy is overweight - 18 stones. She has high blood pressure and has been asked to go back to the surgery for another blood test as her blood sugar was raised? She can’t be bothered. She is too tired and has no time. She is with her mother 3 times a day. The nurse keeps telling her to give up smoking but cigarettes help her cope. She has been so many times with her headaches and dizziness! What she needs is sleeping tablets. She doesn’t understand why they won’t give temazepam to her. They work for her mother. She has taken the odd one from her mother to use, but she is careful how much lambrini she drinks on those nights - never more than one bottle.
Maisy’s Life Story
The Maisy Business Case •Using the fictional character of “Maisy” we identified
examples of “disintegrated care” for Maisy across the health and social care sectors and work shopped how to better integrate her care with the assumption that this would not only improve health and social care outcomes but significantly, save money
•The case focused on validating the concept and approach
for advising organisations on the forming of integrated care models of coordination wrapped around patients using real data
PHD CIC: Who are We? •Social business
•Owned by Smethwick Medical Centre and other partners
•First wave PMS+ 1997
•Provider of Primary ,Extended Primary Care
•APMS provider
•Evolved from Smethwick Pathfinder Healthcare Organisation a PMS plus provider formed from two large inner city practices 10 years ago.
Our Journey … Where we came from
• SPHO led to PMS + contract
• The need for a vehicle to deliver changes in services
• If you always do what you've always done, you'll always get what you always got, and you'll always feel what you always felt
• We formed PHD CIC
New business
• Changing ourselves from within
• Fit for purpose Practice
• Created space for new business
• Incubate our thinking
• New money
Health and well being
• Early intervention
• Upstream population health management
• New service development working with new and different partners
Specifics
•Orthopaedics low new to follow up ratio •Elderly Care Coordinator role •Pioneered 20% reduction in emergency admissions •98% of all diabetes care moved into integrated model – efficiency savings made •New roles Developed in primary care •Community nursing now delivered in house
Evolution •Set up the CIC •INVESTED OWN MONEY •Directors appointed by selection •CEO -recruited from outside the NHS •Social capital raised via Big Issue Invest - leveraged external investment and PCT investment
Why Did We Evolve? • Integrated care needed to deliver LTC savings
•Quality assurance systems on the way---back office support very important especially governance systems
•Do we want to remain the ring holders for our patients ??
•We have to use our registered lists well
•Patient experience will determine patient flows
•Technology innovation not being used for LTC management
•Providers not ready to shift
•PBR in the way
•Currency of provision changed
•Quasi market
Maisy in Evolution
•Primary care redesign •Population health management •Developing a capitated risk bearing budget •Developing an AQC contract
Service Redesign in Primary Healthcare
…while involving stakeholders in the redesign efforts and embracing strong values
Goals
Reaching into ‘hard-to-reach’ communities
Enhancing self-care and awareness of one’s own health needs
Workforce development
Developing innovative ways of accessing services
Measurable Outcomes
Reduce Secondary Care Use
Measuring impact of self managed care
Improving Patient Experience
access
streamlining
self empowerment
Proactive Screening
Value for Money
Workstream Project Description
Specialised Interventions for long term conditions
Care Management
• Telephonic support programme focused on promoting patient engagement and optimising health behaviours.
Group Consultations
• Developing a new style of consultation for long term conditions or recurrent acute conditions, leading to a reduction in utilisation of primary care resources as well as improving access.
Access & Signposting
• Safe, reliable and responsive system where patients are immediately directed to the right care in the most timely and effective manner.
• Also a signposting framework for maximising awareness for patients, clinical and non clinical staff about services available. Awareness
Building
Healthreach • To promote the new and existing health services provided
through SMC and to make them as easy and convenient to use as possible with COMMUNITY involvement.
Skill Mix Development
Supervision & Mentoring & Training
• Development of workforce (including volunteers) through peer and classroom training, supervision and mentoring.
What we did
What we did ….
Risk stratification Targeting “low hanging fruit” but....... In the context of whole primary care system delivering change.
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Determine if medical processes and procedures are
“medically necessary”
Enhance care coordination, adherence to guidelines, and care
completion
Utilisation Management
Case & Disease Management
Prevention & Risk Management
Wellness & Advocacy
Incremental impact on
quality and cost
Delivering personalised education and
engagement across multiple channels
Critical Enablers: Managing Demand
One Stop Shop
Wellness & Advocacy
Demand Management
Information & Contracts
Management
StayingHealthy
ChangingLifestyles
ManagingConditions
MajorHealth Events
Preapprovals / Referrals Management
Disease Management
Data Management & Reporting
Payments Management
Health Risk Assessment & Online Programs
Case Management
Education and Engagement
Concurrent Review
Discharge Planning
Retrospective Review
Contracting and Systems Management
Clinical Decision Support Technologies
Busi
ness
/ M
anag
emen
t Su
ppor
t
Lifestyle Coaching
Financial Risk Management
Sizing Targets and Potential Impact
Some Myths Debunked
Care Management - Early Key Findings
0.032
0.017
0
0.050.037
0.017
0
0.05
Urgent admissions for programme group before and after enrollment
Urgent admissions per patient
month
Urgent admissions for programme and concurrent control groups
Urgent admissions per patient month
Control 2008 2009 Programme
Fewer urgent admissions in the programme group
Assumptions: As part of the initial ideation and solution / problem workshops, it was hypothesised by clinicians
Maisy’s and her mother’s problems peaked at age 50 • Cost grew exponentially
• Patients hit the system more (primary and secondary care) because of aging, added social pressures and increasing risk of (or exacerbation of existing) chronic disease and mental health issues, e.g. depression
• The combination of alcohol and depression is not an uncommon characteristic
• An integrated care service that targets these problems and relieves carer pressures that no one system or service can solve on its own will result in financial savings.
Analytics
•The data demonstrates and validates the following assumptions: •Maisy’s issue is a relatively common problem •It’s an expensive problem •The problem peaks at 50 and grows exponentially from there •There is no gender difference (gender does not impact activity or cost, thereby validating representative patient approach)
How many Maisys ? Once we’d identified Maisy, we next analysed how
many Maisy’s existed within Smethwick’s patient population and how much they are costing the system.
Taking into consideration patients with depression, alcohol and a combination of both, the data revealed 702 patients with 25 or more GP attendances represents £386,040 of annual urgent care costs (approximately 20% of the £1.9M annual urgent care spend in Smethwick).
These 63 complex patients, who are heavy users of many services, are those who would benefit most from integrated care.
Maisy’s Current Story
MAISY
Social Care
Police
Secondary Care
Primary Care
Community Care
Mental Health
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Maisy’s Future Story
MAISY
Social Care
Police
Secondary Care
Primary Care
Community Care
Mental Health
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Problem / Solution Pair - Carer Pressure
Hol
istic
, Int
egra
ted
Appr
oach
Interventions
Problem
Maisy’s mother’s GP practice meets with and listens to Maisy to understand the challenges she’s facing with her mother’s care. This triggers a dementia assessment by a
care coordinator to assess her mother’s capacity and care needs. The care coordinator is then empowered to
coordinate and sign-post her mother’s care as well as where the family can seek additional support. As a result Maisy receives better integrated carer support and her mother
receives the care that she needs.
Dementia Care Coordinator (Family counsel intervention). Does not have to be medically qualified person; Needs to be
someone who can work across the system / agencies / teams.
Assumes that a Mental Health network is in place to help
support.
1. Reduces barriers across general practices
2. Reduces hospitalisation of mother in crisis ( A/E, Inpatient admissions) – 50%
3. Reduces death in hospital (mother) – 50%
4. Reduces Maisy’s (carer’s) use of primary care – 20%
5. Reduces Maisy’s (carer’s) long term use of secondary care use – 20%
6. Short term increase in social care cost (carer support £100 per week (2hrs per week); Long term social care (nursing home cost) will reduce by up to 30%
7. Additional Impacts: Increase in Maisy’s happiness, wellness, ability to take care of her family / children
Maisy continues to crumble under the pressure of caring for her mum who refuses care and is
registered with a different practice from her. Her mother has not received a formal dementia
diagnosis and the practice won’t talk to Maisy because of confidentiality. The stress is leading to
heavier drinking and depression. The agents involved: primary and secondary care, Social
Care, Mental Health
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Solution
Impacts
Lessons Learnt •Population Health Management with the registered lists a priority •Concentrate on pathways in the community – not necessarily activity in hospitals •Care Coordination role of Primary Care with Maisy at the heart of care •Huge developmental opportunities in Primary Care •Clinical leadership – Change Management a must •More integrated working with other agencies andPractices •PROVISION ..PROVISION..PROVISION
GP Attendances per patient per year
Age
Age
Accepted wisdom People use primary care more as
they get older
GP Attendances per patient per year
True ✔
True ✔ or False ✖ ?
Accepted wisdom People use urgent care more as
they get older
Urgent attendances per patient per year
Urgent Care Attendances per patient per year
True ✔ or False ✖ ?
True ✔
Note: Data from 6,249 Smethwick patients >30 years old, April 2009-March 2011 26
Older people use more primary and urgent care
Accepted wisdom
Good use of primary care reduces use of urgent care
False ✖
True ✔ or False ✖ ? Urgent and GP Attendances per year
# of GP attendances per year
Urgent attendances per patient per year
The more patients attend in primary care the more they
use urgent care (Caveat: Without primary care things would be even worse)
Accepted wisdom
Good use of primary care reduces costs in urgent care
True ✔ or False ✖ ? Cost of urgent attendances and frequency
of GP attendances
# of GP attendances per year
Average cost of an A&E attendance (GBP) False
✖ Frequent primary care attenders are the most
expensive urgent care cases. These are complex patients
using multiple services
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Does more primary care mean less urgent care?
Medical
•Obesity •High blood pressure •Glucose intolerance •Smoking •Mother’s Alzheimer’s dementia Mental Health
•Depression •Alcoholism Social Care
•Poverty •Housing •Marital relationship •Carer stress and fatigue •Inability to manage ‘the system’
Maisy’s problem list Services and boundaries
Maisy’sGP
Maisy’s mother’s
GP
Mental Health
Social Care
At least five services and eight boundaries
Urgent Care
• Services are managed; boundaries are not • Boundaries increase exponentially
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Maisy: An example of current state
•Every service is working to do the best it can in the current system •Complex patients have needs that span multiple services •Increased use of urgent care despite heavy use of primary care suggests the health and social care system is not working well for these complex and costly patients •If each service is doing its best then the problem lies at the boundaries between services
And the solution is integration of care across the boundaries?
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Do we agree that…
Maisey’s New Model
Achieved … •To enable this model to operate effectively, new and
innovative ways of working across the health economy and the community were created… Healthy communities collaborative •Information technology leveraged to coordinate care …
Health Fabric •Further, to better manage financial risk and build a
sustainable business model, an integrated care organisation the care cordinated medical home ensures partners coordinate care across the continuum of Maisy’s health and social care needs •Engaging and educating Maisy about her own care to
improve efficiency, health, wellness and cost savings
THE FUTURE... An ACO picture in development •Know how developed to take a commercial offer to
CCGs •Shortlisted for a pioneers bid to take the idea to a
500,000 population in Sandwell and West Birmingham •Products around LTC care coordination being taken
to market •Currently taking a 50,000 + population to a
managed care approach based on service redesign in Smethwick Medical Centre
In Summary… PHD CIC has developed a model using the know-how of a targeted response to populations emphasising
The future of Integration design rests in PRIMARY care as the medical ‘home’
Co-ordinating the care of the patient not just a condition using innovative new technologies and taking on risk bearing AQC type budgets.
THANK YOU To learn how to improve care for Maisys in your community please contact:
Jayne Hunt - [email protected] Jay Sinclair - [email protected] Jaivir Pall - [email protected] Georgina Craig - [email protected] Niti Pall- [email protected]
