Total Care – Admission Reduction Felixstowe Team Launch Autumn 2010

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Presentation transcript:

Total Care – Admission Reduction Felixstowe Team Launch Autumn 2010

Why Pressure on hospital, ambulance service etc Expensive - Unplanned admissions 35% secondary care costs Aged >60 = 45 admissions (65% costs) Variety of reasons trigger admission Potential to avoid: If know patient at risk Combined response of health and social services

Ipswich pilot – Total Care Joint team worked with 5 practices GPs – 66% reduction in home visit/appointments with high risk group Saved £250k in 6 months Commenced/ Discontinued medication for exacerbation e.g.  Antibiotics, steroids, nebulisers Moved into the Red Category - Increased diagnostic monitoring, more visits Dying at home - to reflect patient’s wishes Referrals – outpatients etc Other – respite care, equipment, community bed admission

The East model Project has £0.5m funding and managed by PbC consortia Patient to have >3 categories below 3 or more LTC (not mental health issues) 3 or more admissions to hospital or A&E in 6m 2 or more falls in last 2m. 25 hrs of home care per week Top 3% of GP visits or appointments. Clinical judgment Identify high risk discharges Case management team (social worker, community matron etc) Comprehensive assessment and care plan Case manager co-ordinates future care Identify high risk patients (8-10 per practice) Project has £0.5m funding and managed by PbC consortia

GP/practice input Identify high risk patients & invite them on project GP discuss and agree care plan with case manager Welcome Total Care team into practice Feedback issues etc

Roll-out 3 teams: Woodbridge (DHG, Leiston, Sax & Aldeburgh) Felixstowe – Joyce and Liz Stowmarket (North SBS)