Clinical Lead for Integrated Care Managing Complex Care Anne Hendry Clinical Lead for Integrated Care Senior Associate, IFIC

Complex Needs Complexity involves the intricate entanglement of two or more systems, ( eg diseases, family socio-economic status, therapies)” Nardi et al. 2007   Multimorbidity is a useful trigger for identifying people with complexity. Complex (frail), including those who require support for aspects of daily living or are at end of life, – they will be mainly (but not exclusively) older people likely to benefit from comprehensive multidisciplinary assessment, reablement, anticipatory care planning and care management approaches Complex conditions (functionally independent) – likely to benefit from anticipatory care planning, telehealth and support for managing their conditions and medicines Complex life circumstances – likely to benefit from health coaching, advocacy, benefits advice, mental health support and CPA approach

NICE Guidance 2017 ‘A tailored approach to care’ Multimorbidity refers to the presence of 2 or more long-term health conditions, which can include: defined physical and mental health conditions such as diabetes or schizophrenia ongoing conditions such as learning disability symptom complexes such as frailty or chronic pain sensory impairment such as sight or hearing loss alcohol and substance misuse.

People living in more deprived areas in Scotland develop multiple conditions around 10 years before those living in the most affluent areas

Mental health problems are strongly associated with the number of physical conditions, particularly in deprived areas in Scotland

Guthrie B et al, BMJ 2012;345:e6341; Hughes L et al, Age and Ageing 2013;42:62-69

Coordination and continuity of care Trusted relationships What Matters “My care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes” National Voices, 2012 Coordination and continuity of care Trusted relationships Accessible information and advice Good communication with, and between, staff

Continuity and care coordination Continuity of care: the degree to which a series of discrete health care events is experienced by people as coherent and interconnected over time, and consistent with their health needs and preferences Care coordination: a proactive approach in bringing care professionals and providers together around the needs of service users to ensure that people receive integrated and person-focused care across various settings

Different Types of Care Continuity Interpersonal continuity: the subjective experience of the caring relationship between a patient and their health care professional.  Longitudinal continuity: a history of interacting with the same health care professional across a series of discrete episodes.  Management continuity: the effective collaboration of teams across care boundaries to provide seamless care.   Informational continuity: the availability of clinical and psychosocial information across encounters and professionals. Health Foundation Feb 2017 Deeny et al

Discharge planning from admission Interpersonal continuity Continued relationship and trust between providers & patients/ caregivers Care by the same central providers across care needs Flexible, consistent & adaptive care across the continuum Adapting care to patients behavioral, personal, cultural beliefs and family influences Longitudinal continuity Discharge planning from admission Care and follow up by a professional / team across settings or care needs Service provider linkage and referrals strategies Care navigator or community connector Support from informal carer or social network Management continuity Case management role across-sector Shared collaborative care by an interdisciplinary team Case finding and detection of high risk individuals Proactive regular monitoring for long-term conditions Care planning that incorporates multiple provider perspectives and recommendations. Informational continuity Positive patient - provider communication; engaging patients in the what and why before changing care Information sharing across providers and settings; ‘collective memory’ Shared synchronised care records Standardized and common clinical protocols across care settings

Different Types of Care Coordination Sequential coordination – handover / transfers of care Parallel coordination - collaboration between different professionals with shared responsibility Systems influencers – eg QI tools; incentives, education Øvretveit (1993 and 2009) Health Foundation Feb 2017

Health Foundation Feb 2017 The Health Foundation Øvretveit (1993 and 2009) Health Foundation Feb 2017 Cross sectoral care plans and discharge planning Technology systems that promote information transfer and shared care between settings Co-locating multidisciplinary professionals Shared/collaborative single point of entry to care Primary and specialist care referral pathways / procesess Specialist outreach and case finding Sequential coordination Interdisciplinary teams Care coordination roles (e.g. case/care managers, system navigators, care coordinators or key workers) Formal assessment tools (e.g. geriatric assessments) Individualized and tailored care plans Self-management support and training Specialist support and training Parallel coordination Role clarification and agreements within and between sectors (e.g. accountability agreements, care pathways and protocols Collaborative training and education of providers to improve skills and competencies Quality improvement tools to assess and improve coordination Technology enablers for care coordination System enablers for coordination

Better coordination of care can save money and improve quality, especially: Disease management programmes Case management with multi-disciplinary teams Where use of good data identifies people at risk of deterioration Active outreach services and self-management support BUT Lack of robust evaluation Financial savings not equally shared between providers (funding problem) Need for regulation and governance to create conducive environment as co-ordination neglected

Shifting the Paradigm Current paradigm Future paradigm System geared towards acute / single condition System designed around people with multiple conditions Hospital centred Embedded in communities and their assets Doctor dependent Multi-professional and team based care Episodic care Continual care and support when needed Disjointed care Well coordinated integrated health and social care Reactive care Preventive and anticipatory care Patient as passive recipient Informed empowered patients and clients Self-care infrequent Self management / self directed support enabled Carers undervalued Carers supported as equal partners Low-tech Technology enables greater choice and control

Chronic Care Model

Scotland’s House of Care Collaboratively orientated healthcare professional Organisational Processes & Arrangements Health & care professionals committed to partnership working INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE sustained by the responsive allocation of resources Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working Care & Support Planning Conversation ‘MORE THAN MEDICINE’ Informal and formal sources of support and care Sustained by the responsive allocation of resources

Frailty: loss of physiological reserve Frailty syndromes: Immobility Falls Delirium Fluctuating disability Incontinence FUNCTIONAL ABILITIES Independent Dependent “Minor illness” eg UTI (Clegg, Young, Rockwood Lancet 2013) 18

Frailty as a dynamic functional state Robust Frail Functional Limitation Disability Dependency Potential reversibility of functional decline

electronic Frailty Index Tool for measuring frailty using coded data in electronic primary care record https://academic.oup.com/ageing/article/45/3/353/1739750/Development-and-validation-of-an-electronic

Outcomes by stage of frailty One year outcome (hazard ratio) Mild frailty Moderate frailty Severe frailty Mortality 1.92 3.1 4.52 Hospitalisation 1.93 3.04 4.73 Nursing home admission 1.89 3.19 4.76

Frailty Five Complex care bundle anticipatory care planning medicines review assess carer support needs assess for falls risk and telecare need identify case / care manager

European JA ADVANTAGE Frailty Prevention Approach a single entry point in the community – generally in Primary Care use of simple frailty specific screening tools in all care settings comprehensive assessment and individualised care plans – including for caregivers tailored interventions by an interdisciplinary team – both in hospitals and community - case management and coordination of support across the continuum of providers effective management of transitions between care teams and settings shared electronic information tools and technology enabled care solutions clear policies and procedures for service eligibility and care processes.