Integrated Care Programme (ICP) Locality Hubs Model of Care for Frailty 30 th January 2014.

Integrated Care Programme (ICP)Locality HubsModel of Care for Frailty

30th January 2014

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Context – Integrated Care Programme & Locality Hubs

• ICP forms part of CCG’s Strategic Commissioning Plan

• A major component is the design of a new Locality Hubs model of care for frailty

• Full service launch planned for April 2016

• Fully commissioned service launched by April 2017

• First phase in Woking

3

Context - drivers for change

• Ageing population, people living longer & more people living with chronic conditions

• Cost & demand pressures

• Overreliance on hospitals & residential care

• Not enough focus on prevention & early intervention

• Disconnect between social & medicalised care

• Fragmented delivery of services leading to duplication & a lack of coordination

• GPs as mainstay of the local care system – wider Primary Care, delivered at scale

Fully aligned with recommendations in the 5 Year Forward Review

4

We started with a hypothesis…

~30% of people in an acute bed at any one time never needed an acute admission

~30% of people in an acute bed are receiving no active care & are waiting to be discharged

We have most (if not all) of the services we need to provide best possible care for

our population

So what do we need to do differently?

~30% of people have challenges that are social and rooted in isolation rather than medical needs

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We need to…

• Create greater confidence & capability to keep people safe and well at home, and in the community, without the need for acute admission…

• …by introducing primary care physician leadership into the out of hospital environment for medical care…

• …to better integrate services around our patients….

• …and take a more proactive approach to the care delivery.

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Our hypothesis led us to two key ambitions

1) No one should be in an acute bed because

they are frail&

2) No one should become frail if they can be helped to stay well

Better outcomes & quality of life

Less pressure on the acute

sector

Improved care quality & patient

experience

More cost-effective and

better value care

Optimised health & social care resources

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We’ve created 3 ‘frailty domains’ based on people’s needs

Frailty domains

Mobility & Daily Living

Cognition & Mood

Physical wellbeing

• Mobility and stability• Nutrition and hydration• Continence

Examples of need

• Dementia and rationality• Depression and anxiety

• CV disease with– Diabetes– A. Fib. / CVD– PVD

• Respiratory Disease• Neurological Disorders

• There are many definitions of frailty (E.g. Edmonton scale) and all capture elements of physical, mental and general wellbeing

• The system support needed to help a given patient will depend on the degree of need, the individual’s ability to cope with their circumstances and the degree of family / friend support available

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We’ve quantified the target patient cohort by segment

Adaptive Assisted DependentIndependent EOLC

ManagedTransition

ManagedTransition

ManagedTransition

ManagedTransition

Hub scope

Criteria used to estimate target population by segment

• >75 & identified by GPs as Frail using Edmonton Scale• Identified as at risk from functional decline & avoidable admission e.g.

• Advanced lung function and breathing problems• Progressive neurological problems, including Dementia• In-dwelling catheters• Advanced cardiac disease

• Includes:• Nursing & residential home residents• EoL

~5k ~4.7k ~5.3k = ~15k

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Frailty domains cut across segments creating a ‘matrix of need’

Adaptive Assisted DependentIndependent EOLC

ManagedTransition

ManagedTransition

ManagedTransition

ManagedTransition

Frailty domains


Cognition & Mood

Physical wellbeing

Hub scope

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These needs will be addressed by 7 service lines spanning each domain & segment which together form part of a person’s care plan

Independent EOLC

Frailty domains

Adaptive Assisted Dependent

Adherence & PersistenceAdherence & Persistence

Adaptive Environment & Assistive Tech.Adaptive Environment & Assistive Tech.

Medical Monitoring & TestingMedical Monitoring & Testing

Medication ManagementMedication Management

Emotional ResilienceEmotional Resilience

TransitionsTransitions

Each element to be addressed as part of care plan

w

y

uv

z

x

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Cognition & Mood

Physical wellbeing

Locality Hub

Carers, Family, Friends & Community SupportCarers, Family, Friends & Community Support

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“I do the things that keep me well and I will do them for the long term”

• Patient: nutrition, hydration, alcohol and smoking, hygiene, catheter care, coaching, shared decision support, patient rehab, manual handling advice

• Carer: care plan understanding, available support learning, best practice learning

• Staff: technical training, shared decision making, motivational interviewing

Coaching, training & education

• Exercise classes (mental / physical; regular / trial)

• Meals (at the Locality Hub)Well-being

classes

Adherence & PersistenceAdherence & Persistenceu

INTERVENTION EXAMPLE ACTIVITIES

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“I get the tools I need to keep me mobile, enable me to function day to day & manage my own health”

• Remote monitoring & access (BP, warfarin, lung function, safety, CPAP, telecare, BAS, suction, movement pattern, e-prescribing, e-carte

• Reminder aids (text, email, phone call), pill dispensers• Sensory aids (e.g. hearing aid)

ElectronicDevices

• Walking aids, splints and supports, assistive devices for ADL, other aids

Mobility Aids

Adaptive Environment & Assistive TechnologyAdaptive Environment & Assistive Technologyv

• Home assessments

• Advice on home environment – safety checks

• Bathing equipment, lifts, hoists, ramps etc.

• Meal preparation support

HomeAdaptions


13

“I have the regular check-ups I need to stay well & get treatment quickly when I need it”

• GP led check-up• Nurse led check-up (Practice Nurse/Healthcare Assistant)• Pharmacist led check-up

RegularCheck-ups

• CV, Respiratory, Neurological disorders, Geriatrician, Psychiatry, Podiatry, other

SpecialistConsultation


• Blood pressure & hypertension• Hearing• Gait• Visual Acuity• Memory

Diagnostics & Screening

w

Minor Elective Procedures

• Continence• Skin Assessment• Bloods & Urine tests• Bladder screening• Spirometry

• Catheter replacement• Stoma Care• Infusion treatment• Sigmoidoscopy

• Endoscopy/Colonoscopy• Fluoroscopy• Pressure sore care• Epidural steroids• IV Care


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“I’m on the medications that best suit me, I know how to use them properly & I’m reviewed regularly”

• Review of drug portfolio, drug-disease interaction, side effect and A/I barrier

MedicationReview

• Pharmacist supported chronic medication dispensing and intravenous treatmentDispensing

Medication ManagementMedication Managementx


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“I make best use of the resources around me & my carers are supported to help me”

• Local community centres and faith groups• Voluntary opportunities• Support to use Surrey Information Point• Neighbourhood schemes• Food banks etc.

Information & signposting

• Carers assessment and adviceAssessment for carer support


• Signpost to local carer groups and services• Registering with carers emergency respite services • Practical care advice and training• Dementia café

Carer support & training

y


“I feel supported in my caring role and get support to have a life outside caring”

16

“I feel happy & able to cope with my circumstances & I know where to get help when I need it”

• Named care coordinator• Telephone outreach• Befriending• Personal coaching – activation• Counselling

Individual Support

• Meeting at the hub• Good neighbour schemes• Use of community centres

GroupSupport

Emotional ResilienceEmotional Resiliencez


17

“I know what to do when things change, & the people that know me & my circumstances are there to support me”

• Single point of contact

• Immediate management of acute episode / exacerbationCrisis

Management

• 2 hour response service• Same day response service• Wound management• Outpatient specialist consultation for new condition

Rapid Response

Transitions Transitions {

• Proactive in-reach into A&E and hospital to pull people through the urgent care system

• Rehabilitation

Discharge to Assess


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Hospital

Locality Hub – conceptual model (one-stop-shop)

Tra

ns

po

rt

X

Place of residencee.g. • Home• Nursing Home• Residential Home• Extra Care Housing

Hub out-reach

Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector

Self Care

Care packages

Hub out-reach into hospital to proactively pull people through the urgent care system

Diagnostics

Pharmacy

Support services

A physical building next to a community hospital providing an integrated frailty service for people & their carers with all locality GP practices and services operating in a network

Locality Hub

People are referred to the Hub from local services based on flags for high risk & formal screening at GP surgeries

Assessment, Care Coordination & Care Planning

Adherence & PersistenceAdherence & Persistence

Adaptive Environment & Assistive Tech.Adaptive Environment & Assistive Tech.


Medication ManagementMedication Management

Emotional ResilienceEmotional Resilience

TransitionsTransitions

w

y

uv

z

x

{


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Indicative high-level roadmap

14/15 15/16 16/17 17/18March March March

DevelopServiceSpecification

Run ProcurementAll Localities

(Service fully commissioned)

WokingPilot Live

Thames Medical

SASSE

Woking

3 Locality Hubs(fully operational)

Implementation Plan in development

Integrated Care Programme (ICP) Locality Hubs Model of Care for Frailty 30 th January 2014.

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