1. Total Care – Admission Reduction Felixstowe Team Launch Autumn 2010

2. 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

3. 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

4. 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

5. 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

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