1. Improving the visibility and sharing of the patients data for multi-disciplinary working NATIONAL DOCMAN USERGROUP 3 RD July 2014 Presenters Dean Holliday, Project Portfolio Manager, General Practice, proactive and integrated workstream, SLIC Nigel Brokenshire, IT Lead, SLIC Sonia Hall - Practice Manager/ Advanced Nurse Practitioner Concordia Parkside and Melbourne Grove

2. 1 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Introduction to Integrated Care Multi-Disciplinary working Community Collaborator Clinical Perspective Choose: Informal Agenda

3. 2 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives Southwark and Lambeth covers a population of 600,000 people; we have world-class medical institutions but worse than average health outcomes and deprivation St Thomas’s Hospital King’s College Hospital SLaM Guy’s Hospital Source: Health Profiles 2013

4. 3 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives Leaders and citizens across the care system have come together to improve value : raising quality and experience whilst reducing overall costs Providers of careCommissioners of care Academic partners Local CCGs and LAs LAs, GPs and FTsAHSC Southwark and Lambeth Integrated Care

5. 4 Version: DATE: AUTHOR: SLIC 03/07/2014 1 L2 L1 L3 Proactive management: the holistic needs of individual over 65s year olds were often not systematically known in general practice, with little/no care plans in place, and without any support structure to help interagency care planning b Clinical pathways: there was too little focus on preventing ill health in the general population specifically in areas of Falls, Infection, Nutrition and Dementia a Too little emphasis was placed on keeping people healthy and avoiding the development of crises Early identification and intervention to avoid crisis 1 ?? Internal and external processes were making it difficult to discharge people in a timely and effective way and inadequate community provision of reablement services was impacting on flows into and out of hospital GP A&E There were too few options other than the hospital, so people who didn’t need it ended up in acute care Providing alternative urgent response 2 Improving hospital discharge and reablement services to maximise independent living 3 No way to view GP record within an Emergency Department Limited ability to correspond electronically between GPs, hospital, community and social care Multi-disciplinary discussions had no secure way of discussing information about a persons care other than via e-mail Using IT to support integration 4 CMDT Older People’s Programme Aims

6. 5 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives Promote contact and collaborative working between practices and partner organisations Demonstrate a better use of staff time, to contribute to the CMDT meetings Increase the continuity of patient care planning and help to reduce duplication of effort Provide a centralised patient/client case summary that is accessible to relevant parties Provide a secure environment to share patient/client data Provide an audit trail of care planning and delivery Anticipated Benefits

7. 6 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives One for the techies!

8. 7 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives Approach / Timeframes

9. 8 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives As at the end of the pilot Sept 2013 we had: 2 out of 6 Community MDTs using Collaborator 23 active users (classroom trained & 1 to 1 sessions) 42 cases loaded As at 1 st July 2014: All Community MDTs able to use Collaborator We now have ~70 users Estimated 150 patients case discussions undertaken Support Model 1 to 1 sessions Sharing learning at CMDT meetings 3 PDF guides and 17 online videos Collaborator progress to date

10. 9 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives Ability to view and contribute

11. 10 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives Evaluation of Collaborator against SLIC objectives and aspirations Continue to keep it simple ………. 3 stages – pre, during and post CMDT Share information in advance via Collaborator Allow CMDT members to contribute to case notes Electronic view during the meeting (IG, paperless, adding value) Actions added to Collaborator post meeting and assigned to CMDT members Looking forward and action planning ?

12. 11 Version: DATE: AUTHOR: SLIC 03/07/2014 1 Southwark and Lambeth Integrated Care: Working together for healthier and happier lives Questions? Thank you “I have found using DOCMAN Collaborator to be an overwhelmingly positive experience. It has made working in the CMDT much easier, as now it is possible to share information in a safe, efficient, Caldicott compliant manner. It has dramatically reduced my preparation time and provides a secure means of communication” - Dr Dan Bailey Consultant Physician Department of Clinical Gerontology King's College Hospital NHS Foundation “I have found using DOCMAN Collaborator to be an overwhelmingly positive experience. It has made working in the CMDT much easier, as now it is possible to share information in a safe, efficient, Caldicott compliant manner. It has dramatically reduced my preparation time and provides a secure means of communication” - Dr Dan Bailey Consultant Physician Department of Clinical Gerontology King's College Hospital NHS Foundation “Using Docman Collaborator has been by and large a very positive experience. With lots more functions still to explore I see it certainly meeting the needs of the CMDT in a safe efficient manner” -Brenda Donnelly Co-chair South Southwark CMDT Practice Nurse, Elm Lodge Surgery “Using Docman Collaborator has been by and large a very positive experience. With lots more functions still to explore I see it certainly meeting the needs of the CMDT in a safe efficient manner” -Brenda Donnelly Co-chair South Southwark CMDT Practice Nurse, Elm Lodge Surgery