How can we co-ordinate care from the information perspective

Experience from Carmarthenshire Chronic Conditions Demonstrator, Wales

Leo LewisSenior Fellow

International Foundation for Integrated Care

Health and social care has tended to create a series of simple,

disconnected, linear systems each designed to maximise one goal…

…and yet we have the knowledge, technology and imperative to formulate a sustainable way of delivering services rather than pursuing approaches that

simply mitigate negative impacts.

Building the CCM Model

Predictive Risk Tool

Telehealth and Telecare

Generic CCM support worker

Generic Care Pathway

Core MDT CCM Teams

Locality GP

Clusters

Care Co-ordinator

CCM Model – population based c50,000

Ecosystems are complex, interconnected and interdependent and designed towards an optimised

overall system

From information to understanding

CCM model and framework: role of care co-ordination

• Identify, plan and co-ordinate services to meet needs at each of the model’s four levels

• Liaise with patients, carers and service providers from private, voluntary, statutory and independent agencies

• Monitor patient progress and service delivery across primary, secondary, community and social care

• Co-ordinate primary care collaborative networks and networked services

• Advise on the commissioning of chronic conditions services

Confusion!

Views on the Care Co-ordinator role:• The person who took the lead in ensuring the Unified Assessment process was implemented for service users – either health or social services• Case Manager• Care Management• Community Chronic Disease Management Specialist Nurse

Clarification

Analysis of Skills for Health competencies for care co-ordination, care management and case management:

• 154 competencies delineated into three functional areas:– Strategic co-ordination and planning at a population level– Clinical/social care co-ordination focused on delivery of

services to individuals– Data and information competencies to support other

roles

Care Co-ordinator became

Care Services Planning Co-ordinator

Based on mid year estimates 2008 population growth & 2008/09 QoF as a % of the total registered population 2009

Planning: chronic condition prevalence

Projected Over 75 years QoF Events by disease 2009 to 2014 & 2019Towy Taf Locality

622

408

2823

254

1110 13

69

281

252 52

1 742

39

339

65

628 689

503

49369

5

456

3155

284

1241 15

30

314

282 58

2 829

44

379

73

702 770

562

55181

2

533

3687

332

1450

1788

367

329

680 96

9

51

443

85

820 900

657

643

0

500

1000

1500

2000

2500

3000

3500

4000

AF

Asth

ma BP

Canc

er CHD

CKD

COPD

Dem

entia

Depr

essio

n(d

iagno

sis) DM

Epile

psy HF M

H

Obe

sity

Stro

ke/T

IA

Thyr

oid

Popu

lation

>75

/ 10

QoF Disease area

Num

bers

of p

atie

nts 2009Evts>75

2014 Evts>75

2019 Evts>75

Planning and co-ordination: service utilisation

Emergency medical admissionsEMAs by Chronic Disease; Carmarthenshire Residents

0

100

200

300

400

500

600

700

800

900

COPD HF Diabetes All Type 1 Type 2 Other Diabetes

Condition

Nu

mb

er Calendar Year 2004

Calendar Year 2005

FY 06/07

FY 07/08

Planning – population and individual: predictive risk tool

Locality workforce profile

Individual care co-ordination: care plan

Planning and care delivery: health and social care directory of services

Information to support others: multi-disciplinary team meetings

Planning and delivery: chronic conditions generic care pathway

Chronic conditions – average length of stay:

measuring achievement

10

9

8

7

6

Month

Da

ys

_X=6.817

UCL=7.446

LCL=6.188

1

6

551

Rolling 12 Months' Average Length of StayCOPD Emergency Admissions

I Chart of Carmarthenshire by Month

5.75

5.50

5.25

5.00

4.75

4.50

Month

Da

ys

_X=4.813

UCL=4.971

LCL=4.656

Rolling 12 Months' Average Length of StayCHD Emergency Admissions

I Chart of Carmarthenshire by Month

Source: HSW Web Indicators SaFF 10

(Target 5.7 days) (Target 5.7 days)

From information to understanding:our integrated community services care model

Care Services Directory Menu

Carmarthenshire Community Services Care ModelIdentify Cases Initiate Care Process Care Delivery and ReviewCare Assessment and Planning

Information Point for Citizen, Carer, and Professional

Single Point of Access

24/7Response

Unplanned Referral

Initial Referral

Generate Intervention

Requests

Diagnostic Intervention

Assess

Planned Community Services Intervention

Urgent Community Services Intervention

Review and Assess

Case Finding

Self Referral

Allocate Key Worker

Enter Referral

Unplanned Community Services Intervention

Unplanned Intervention – (not CS)

Re-

allo

cate

Prism and PARR++

GP Registers

Case Lists

Activity Reports

Assessment & Prioritise

Update H&SC

Records

Update H&SC

Records

Update H&SC

Records

Escalate to Community MDT Team Escalate

Main CCM Delivery Providers include:Social Care, District Nursing, Canllaw, DRT, CDM, General Practices, Out of Hours, Ambulance Trust, Voluntary Sector, Independent Sector, ART , TC/TH

Integrated Health and Social Care Register

Discharge

CommunityMDT Team

Update H&SC

Records

Produce Care Plan

Planned Intervention – (Not CS)

Normal

Unplanned

Info ResourceNormal PathUnexpected Path

Integrated, comprehensive solution that addresses multiple challenges simultaneously and coherently.

Rhayader Home Support Service

You never change things by fighting the existing reality. To change something, build a new

model that makes the existing model obsolete.

Michael Pawlyn 2013