1. Creating value : Integrated care in East London Charles Gutteridge CCIO Bhavi Trivedi Darzi Fellow

3. 3 core elements to our programme A people’s health data movement Empowering clinicians with point of care information and outcomes data Developing data for population health

4. Patient and citizen information system Building a learning system Developing the data Projects – At the point of care – smoking cessation – Supporting next steps in care pathways – Aggregating data – Communicating across boundaries – Patients and families

5. Governance arrangements across NEL 5 NEW – North East London Clinical Senate NEW – North East London Clinical Senate Primary Care Transformation Board BHR Integrated Care Coalition (ICC) Integrated Care Steering Group City & Hackney WEL Transforming Services Together Programme Board (TSTPB) Urgent Care Board (System Resilience Group) Urgent Care Board (System Resilience Group) Communications Working Group Communications Working Group Acute Reconfiguration Implementation Group Acute Reconfiguration Implementation Group 9 Clinical Workstreams 5 Enabler Workstreams Clinical Reference Group WELC Commissioning Clinical Strategy Group (CSG) North East London Advisory Group

6. 6 5 36 Tower Hamlets practices, 8 networks, 2011 1 2 3 4 5 6 8 9 10 7 11 12 15 13 16 14 17 18 19 24 21 22 20 23 25 26 27 28 29 30 31 32 33 34 35 36 Pop: 28,956 Pop: 23,868 Pop: 38,529 Pop: 33,948 Pop: 27,692 Pop: 25,549 Pop: 36,433 Pop: 30,034 Delivering ‘care packages’- Priced on ‘ideal delivery’ 70% payment up front 30% on year end performance Network has total control on how to allocate these funds Management resource- 150K per network Networks initially not legal entities Requirements for network level clinical leadership Network management structure :

9. Connecting up for benefit Dr Charles Gutteridge Clinical Informatics

10. Maternal smoking statistics Count Current smoker1328 Ex-smoker3498 Never smoked20290 Unknown39 Grand Total25435

11. Risk stratification Co-ordinated care Reduce emergency attendances Reduce emergency admissions Improve outcomes QAdmission ® algorithm (Consent) (Enrol) East London Integrated Care Programme High Moderate Low Very low Very high

12. 3 different community approaches Community matrons Face to face Community matrons Face to face Community matrons Face to face Health analytics Rapid response team Telephone consent Rapid response team Telephone consent GP EMIS web EMIS community GP EMIS web EMIS community 8 networks Care navigators Telephone consent 8 networks Care navigators Telephone consent Feedback from hospital systems Cerner Millennium HIE Cerner-EMIS Feedback from hospital systems Cerner Millennium HIE Cerner-EMIS Waltham ForestNewhamTower Hamlets GP EMIS web EMIS community

13. Reasons for attending the ED PainShortness of breathGenerally UnwellFallChest PainConfusionChest infection

14. LRTI UTI Gastroenteritis IHD COPD Heart failure Superficial injury Fracture Electrolyte imbalance Unspecified chest pain Unspecified fall / collapse Unspecified abdominal pain Unspecified MSK pain Primary diagnosis at discharge (ICD-10)

15. AA – Automation and aggregation What do you mean it is binary? I think he is speaking in SNOMED

16. Target population for community-based intervention 5103,0247,074 ≥ 1 ED attendance ≥ 4 ED attendances

17. The answer is in the data…? Clinithink CLiX ENRICH

19. Preliminary findings The method allows for encoding of free text narrative to identify features The features can predict risk of multiple attendances to the ED with an accuracy of 83% Further validation is underway

21. Learning with citizens and patients

22. Generational health