Integrating Care for Frail and Elderly

The overall approach High quality services Integrated Identification Care …of people at high risk of illness or complications Good care in the right place at the right time Health and social care built around people’s needs Adequately resourced services responsible for identifying people at high risk Training Maximum use of IT capability Clearly defined pathways Sufficient capacity and skills Quality of care information measures & feedback Creating an environment that promotes collaboration between existing services Investing in services/roles that promote integrated care Contractually incentivising an integrated care approach Introduction to the FE P and an overview… What? The programme is one of 5 investment programmes in the CCG- Programme started in July 2013 for 5 years to mid 2018- aim to improve outcomes and quality of life for all frail people in Camden Who? Our working definition is 75+ with one or more LTC and a non elective admission in the last 12 months OR under 75, with complex health and social care needs (and clinically judged to benefit from a case management approach) 3 streams above show: Identification- case finding, proactive approach, early identification and prevention…so keeping maximising functional capabilities for longer HQS- summarised by right care, right place, right time… Integrated Care.. All efforts to reorganise care more effectively/ efficiently, around the patient. Programme series of IC pilots and approaches- different kinds of integration. Co-location (SW’s), partnership/ improved teams/ functions (MDT), services out of hospital into the community (community geriatricians) Improved Outcomes Prevention where possible - Early diagnosis - Consistent quality - Patient consultation - Review and reconfigure if necessary

Integrating Care for Frail and Elderly Primary Care Community Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care Programme is relevant across the health economy, but particularly to primary care… Risk stratification approach- supports proactive management in primary care, to support identification of high risk patients, added to the frailty register (and DES), frailty care plan produced in EMIS, decision made about where patient to be managed- at hub or practice MDT- so integrated working and case management of patients. Supports patients who may otherwise fall through the net… Hasib will say more about this a little later Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Component 1: MDT Primary Care Community Care Secondary Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care Many frail and older patients described experienced fragmentation and lack of coordination- MDT hub was initiated in 2013 in response to this. Also part of a structured integration of clinical services in community hubs (The Camden Integrated Care Service). Many of these patients have a wide range of support needs and are at risk of poor health outcomes without an integrated approach. It has developed into an established team framework for delivering integrated care, meeting on a weekly basis to manage risk and provide high quality care coordination for patients. Membership comprises acute, community and intermediate care, mental health and primary care, social care and voluntary and community sector professionals. Referrals are made from primary care, community care, social care and the acute sector- patients are reviewed an average of 4 times and discharged after 19 weeks, with the majority stepping down to management through practice based MDT’s. Stuart will say more about this.. Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Component 2: LCS for Complex Care Primary Care Community Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care All of these components of identification and assessment, ongoing case management and multidisciplinary working are underpinned by a locally commissioned service (LCS) for complex case management- this includes support for practice based MDT’s. In December 2014 a variation was issued to build on the success of the LCS, increasing capacity in primary care for proactive review and home visiting of patients on the frailty register, carrying out pre-frailty assessments and afternoon home visiting for emergencies. Lance will say more about this later… Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Component 3: Frailty Education Primary Care Community Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care Education module to view through the GP website- also playing in the background today on a big screen for viewing in the breaks. Subjects covered include defining frailty, complex care LCS, safeguarding, prescribing for the elderly.. Care planning Version 2… social workers in primary care, risk stratification, care navigation, and case management… Accreditation via completion of short quiz at the end.. Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Component 4: CIDR Primary Care Community Care Secondary Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care The Integrated Digital Record for Camden residents, registered at Camden GP Key data can be viewed in one place by health/ social care professionals with patient consent- includes events, diagnoses, medication, risks. Covers Primary Care, ASC, Community, MH and UCLH/Royal Free. Underpins Integrated ways of working- primary care, social care, MDT CIDR- rolled out borough wide in 2014- development cost base low- under £1m Outcome: care is more efficient, and preventative.. Care more efficient- because health professionals no longer have to request information that is now in one place Preventative- clinicians now have a rounded care record, improving decision making and earlier identification of need Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Component 5: Complex Care Nurses Primary Care Community Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care 4 nurses covering all of Camden- working with patients with complex needs Skilled community support to liaise with practices and provide multi-disciplinary support Support the Camden case management model + LCS.. depth case management to those at high risk of hospital admission – organising locality based meetings And supporting practice based and borough wide MDT working- We are very pleased Sue has come today to tells us more about this key service… Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Component 6: Community Geriatricians Primary Care Community Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care Essential to integrated frailty piece- brings care far closer to patients. Key pilot components… significant population of FE across 470 beds in care facilities… and some frequent hospital admissions. MDM’s with named GP’s for each facility ++ advance care planning, medication reviews, post hospital discharge care review ‘Bridges’ primary and secondary care effectively- MDM model valued by care home staff, GP’s and nurses- upskilling of staff and multi-disciplinary working.. Also, specialist support into borough wide MDT And programme of domiciliary visits- CG’s out of hospital and into visits in the community for patients who can’t come to clinic Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Component 7: Social Care in Primary Care – and Care Navigators Community Care Case Management Borough Multi-Disciplinary Team (MDT) Risk Stratification High Quality Service Community Geriatricians Care Navigation Identification Integrated Care CCM LCS Camden Integrated Care Service (CICS) Social Care in Primary Care Co-location of social workers in 5 GP practices in Camden- aims to better manage patients with the most complex health and social care needs Evidence based approach supported by RCGP + CSW- also strong local evidence from CICS since 2012 that SW’s play critical role in integration arrangements and delivering patient benefits (enhancing Q.O.L, delaying/reducing need for care and support, partnership working) Delivering better integrated assessment for patients- and improving inter professional skills and communications Navigators- 6 borough wide. Linking up to 1200 patients pa in with VCS, supporting patients at risk of DNA’s and supporting practice based MDT’s- resource finding/ problem solving Tracy is with us today to present on the SC in PC pilot- and Sharleen is here to take us through the new CN service Secondary Care Platform - Camden Integrated Digital Record (CIDR) Education Module

Trends in the observed and expected emergency admissions (all) for those aged 75+ years resident in Camden LA, 2005 to 2013 (Source: Nuffield Trust). Camden is one of only five areas nationally that have seen reductions in key metrics. Camden is bucking the trend for increased activity in emergency admissions, COPD, fractured neck of femur and A&E attendances, all in the over 75 year olds. The period of time being assessed covers the nine years from 2005 to the end of 2013. Although Camden’s A&E attendances have actually increased over the time period assessed, this is only by 2 percent against an average of 13 percent across the rest of England.

One outcome important for older or frail patients is to increase the number of days spent at home i.e. not spent in hospital. The chart above shows the impact the MDT is having on the patients case managed by the team. 70% of patients spent the same amount, or more time at home after MDT management, despite these patients being complex and likely to be admitted. These results shows a statistically significant increase in the mean time spent at home in the after being added to the MDT caseload. So the MDT is making a real difference to outcomes!

Financial impact of the MDT The savings below represent activity removed from acute hospitals in A&E and emergency admissions, in the 12 months following the patient’s first MDT review (or up to the date a patient is no longer registered in the borough, or is deceased). A&E average monthly saving 2014 is £2,606 Emergency admissions average monthly saving 2014 is £32,988 13

Next steps – Formalised Frailty Service Model 4 Level of need: severely frail Care setting: acute/community/home Level of need: moderately frail Care setting: primary care/community/home 3 2 Level of need: mildly frail Care setting: primary care/community/home Anticipated move towards an outcomes based service model from April 2016- frailty hierarchy- coordination of care and management of risk by tier of need Some of the current pilots and approaches would transition into this new arrangement The aim is to build on success with integration arrangements for this patient group, considering the best form for a service across acute/ non acute health and social care… 1 Level of need: pre-frail Care setting: primary care/home

Next steps – Formalised Frailty Service Model Primary Care Hospital Care Community Care Middle circle represents the Integrated Practice Unit, that draws together key services and players to successfully manage the cohort of frail and elderly