Sasha Karakusevic

We have achieved substantial improvements for our community and receive positive feedback from patients and the public Both the Care Trust and Foundation Trust were finalists in the HSJ PCT/Acute Trust of the year in 2009 But we know we can and must do better

1991 Whole district trust GP fund-holding 2000Integrated Care Network plan 2005 Torbay Care Trust 2009Integrated Care Organisation pilot

 Partnerships  Innovation  Managing the system  Nurses and workforce  Diagnostics and decision support  24/7 versus local  Facilities, equipment and co-ordination

1991 Working in Brixham 1995 Her mother needs a hip replacement, spends 2 weeks in Exeter having waited 12 months for surgery. Has a stroke 1 month later and spends 30 days in Torbay and 60 days at Paignton before discharge to a nursing home for 6 months. Dies Retires. Husband has MI, waits for 3 weeks in hospital before transferring to London for surgery Husband develops heart failure and dies 18 months later following 4 admissions

 Mother has hip replacement 3 months after seeing her GP. Date arranged to enable holiday with daughter pre-op. Enhanced recovery and VTE prophylaxis mean mum home 3 days post-op without complications.  Husband has chest pain. Calls 999 and has angioplasty 74 minutes later. Changes lifestyle.  Couple living happily and enjoying grandchildren.

Change Population Estimated non-elective admissions Cash for non- elective admissions £67m +0 Cash per case£1825£1525-£300 No change! Add £13m £82 each Say £500 per family And this in only 25% of the health budget

Conditi on No. Condition NameNew Coding New Weigh t Old Weight 1 Acute myocardial infarction I21, I22, I23, I252, I Cerebral vascular accident G450, G451, G452, G454, G458, G459, G46, I60-I Congestive heart failure I Connective tissue disorder M05, M060, M063, M069, M32, M332, M34, M DementiaF00, F01, F02, F03, F Diabetes E101, E105, E106, E108, E109, E111, E115, E116, E118, E119, E131, E131, E136, E138, E139, E141, E145, E146, E148, E Liver diseaseK702, K703, K717, K73, K7481 8Peptic ulcerK25, K26, K27, K Peripheral vascular disease I71, I739, I790, R02, Z958, Z Pulmonary diseaseJ40-J47, J60-J CancerC00-C76, C80-C Diabetes complications E102, E103, E104, E107, E112, E113, E114, E117, E132, E133, E134, E137, E142, E143, E144, E ParaplegiaG041, G81, G820, G821, G Renal disease I12, I13, N01, N03, N052-N056, N072- N074, N18, N19, N Metastatic cancerC77, C78, C Severe liver diseaseK721, K729, K766, K HIVB20, B21, B22, B23, B

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b. 1928, lives forever

Excite, delight, simplify

Preventative Actions taken to avoid onset of known conditions Immediate Intervention Services in community which prevent admission to acute Acute Safe and efficient management of condition during acute intervention Reablement Services provided to maximise independence following acute admission or crisis Palliative Providing high quality care during end of life and enabling patients to die in place of choice Virtual Pooled Budget for Older Peoples’ Care Assistive Technolog y to support COPD patients Emergency Care Practitioner s supporting falls RACE Clinics Primary & secondary care Medical Model Emergency Admission to Hospital for complex conditions Hospital Discharge Co- ordinators Community Hospitals Medical Evaluation Orthopaedic Pathway COPD/CCF /Dementia in Nursing Homes End of life care Training

 Self care when possible  Tele-health support for high risk periods  Packages of care optimised to maximise benefits  Pro-active intervention when markers indicate increasing risk

 Investments to optimise capacity of local care settings and teams  Efficient support to optimise decision making and promote flexibility  Real time feedback of results and alerts accelerates improvement in outcomes  Virtual activity  Specialists support frontline teams

2020 Getting more frail and forgetful. Husband has diabetes and some heart failure. Daughters live in London and Scotland Local support network in place (based in local nursing facility) to respond to issues detected by home monitoring system. Mr Smith has not needed to visit practice or hospital due to real-time monitoring and medication management system. Daughters can support care through video link and access to shared records