Integrating Care Getting it Right for Jessie

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1 Integrating Care Getting it Right for Jessie Dr Anne Hendry National Clinical Lead for Integrated Care JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing

2 Self Management Strategy 2008 Long Term Conditions Action Plan 2009 From 06/07-10/11 14% reduction in bed day rate for COPD; Asthma; CHD; Diabetes

5 Number of people in Scotland living with two or more long term conditions

6 People living in more deprived areas in Scotland develop multiple conditions around 10 years before those living in the most affluent areas

7 Mental health problems are strongly associated with the number of physical conditions, particularly in deprived areas in Scotland

8 What Matters to Me Coordination and continuity of care Trusted relationships Accessible information and advice Good communication with, and between, staff

10 Multiple Conditions Action Plan Ten Local Actions on three levels: Whole Person - care planning and consultations that help people to have control over their conditions, care and support and to achieve their personal outcomes Whole Team - integrated care and support that builds on local community assets and promotes independence, wellbeing and resilience Whole system - pathways that are designed around people with multiple conditions and to reduce health inequalities National actions Leadership, research, innovation and improvement infrastructure

12 Action 1: Make sure health and social care staff really listen to those they provide care and support for and help people to achieve what matters to them. Action 2: Make sure that appointments provide enough time for the person to talk about what really matters to them and about their physical, psychological, emotional and spiritual wellbeing. Action 3: Increase the use of Anticipatory Care Planning, Carer support plans and Key Information Summaries. This will mean that people, and those who support and care for them, are better prepared to deal with health problems which may fluctuate or get worse over time. Action 4: Pharmacists more regularly do reviews with people who take many different medicines and support them to understand and to manage their medicines at home. JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

13 Action 5: Introduce local volunteers and new roles in GP practices to simplify access to local sources of community support, including support for unpaid carers. Action 6: Increase the use of day to day technology to help people to have more information and control over their own health and care. Increase access to digital information, home monitoring and video consultations to reduce the number of appointments they need to attend. Action 7: Make every health and care contact an enabling experience and an opportunity to improve health and wellbeing. Action 8: Support staff to learn from each other so that specialist staff have better general skills, and staff in community teams develop extended roles. JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

14 Action 9: Managed Clinical Networks work together to develop care and support pathways and guidelines that make sense for people who have multiple conditions. This will help individuals and staff to make the right decisions and ensure people with multiple conditions have the right care, support and rehabilitation, including support to remain in work. Action 10: Identify people with multiple conditions so that they can access the right level and type of care and support as their needs change. This should include coordinated health and care services, along with support from peers, third sector and use of technology. JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

15 Anticipatory Care Planning JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

16 SPARRA Risk Prediction Tool How many previous emergency admissions has the patient had? What age is the patient? How many prescriptions? How many outpatient appointments? Any A&E attendances in the past year? Any prescriptions for e.g. dementia drugs? Or substance dependence? Hospitalisation (3 years) Psychiatric Admission (3 years) Any previous admissions for a long term condition (such as epilepsy? Outpatient (1 year) Emergency Department (1 year) Prescribing (1 year) What type of outpatient appointments did the patient have? Any recent admissions to a psychiatric unit? Outcome Year (1 year) PRE-PREDICTION PERIOD OUTCOME PERIOD

17 SPARRA Cohorts Age Deprivation Prescriptions in specific BNF chapters Frail Elderly Emergency bed days LTC related admissions All cohorts Emergency / elective / daycase admissions Polypharmacy Younger ED ED attendances Alcohol/ substance misuse related admissions New OP attendances Prescriptions for specific groups of drugs New OP attendances for MH Psychiatric admissions LTC Prescriptions/admissions indicating particular conditions Deprivation

18 Anticipatory Care Continuum of Risk 2 nd choice for QOF ACP 1 st choice for QOF ACP SPARRA SCORE < 20% 20-40% 40-60% > 60% Long Term Conditions People with lowest risk of emergency admission to hospital. Likely to need simple information, advice and support to help them to stay well and manage their conditions People at moderate risk of emergency admission. Likely to attend the practice or a nurse specialist for follow up Their ACP is usually best developed by the GP and the Practice team Patients at highest risk of emergency admission to hospital Likely to be receiving care or managed by the Community Team Many already have an ACP Their ACP is usually developed by the Community Team or nurse specialist involved Lifestyle Interventions

Anticipatory Care Plan and Key Information Summary Shared electronic

30000 25000 Total KIS Patients Demographics Medication Information

Involved Important Medical History Homecare Support Treatment ceilings

19 Anticipatory Care Plan and Key Information Summary Shared electronic summary Available 24/7 across Scotland in multiple care settings Total KIS Patients Demographics Medication Information Allergies and Adverse Reactions Next of Kin and Carer Details Agencies Involved Important Medical History Homecare Support Treatment ceilings Resuscitation wishes Feb Mar Apr May Jun July Aug Sept Patients

20 Key Information Summary

Dr Stuart Cumming NHS Forth Valley Margaret s story Margaret age 84, lives alone, diabetic, CHD and has been admitted twice in 12 months - confused?cva.

21 Dr Stuart Cumming NHS Forth Valley Margaret s story Margaret age 84, lives alone, diabetic, CHD and has been admitted twice in 12 months - confused?cva. Diagnosis UTI / low sodium Discussion with Margaret and her daughter - ACP developed Key Information Summary (KIS) - prone to UTIs and delirium. KIS accessible to Primary care team / OOH / NHS 24 /SAS Polypharmacy review Team meeting to raise awareness of management of delirium Power of attorney in place Mobile Alarm in place Just in case antibiotics in house Daughter s contact details available

Rapidly progressive MS Communication, airway, mobility, care and nutritional issues

spend more quality time at home with family and friends Laura 2006 Continuous, integrated

care Collaborative Work with Primary Care, REACH, Complex Care and Local Authority Laura

22 Rapidly progressive MS Communication, airway, mobility, care and nutritional issues Medication management and symptom control Childcare Carer Support Laura age 41 I want to spend more quality time at home with family and friends Laura 2006 Continuous, integrated and preventative care Home adaptations Telehealth 24/7 care package PEG feeding Respite care Collaborative Work with Primary Care, REACH, Complex Care and Local Authority Laura was cared for 24/7 at home until she passed away in She has had no unscheduled hospital stays in 8 years

26 NHS Forth Valley KIS/EPC Uploads / / April May June July August September October November December January February March

Accesses to ekis 700000 Total 633204 619641 600000 500000 511498 469988 512518

27 Accesses to ekis Total Total

Specific Access in one month 60000 50000 40000 30000 20000 Areas accessing ekis Other

28 Specific Access in one month Areas accessing ekis Other Areas accessing ekis OOH Areas accessing ekis SAS Areas accessing ekis NHS

29 Users in A&E Information is clear and concise Would be good if we could also write to KIS rather than read-only Anticipatory care information particularly useful Some of the KISs in pilot were of limited quality Good that it is not just for palliative care This information could dramatically improve the care we provide

30 What GPs liked Good breadth of information Ability to add descriptive text Excellent for sharing info with relevant others Structured, concise and easy to fill in Easy to use and navigate Good design and workflow

31 Testing ACP in Care Homes 346 ACP completed 55 Care home residents died preferred place of care 129 residents followed for 6 months 37 Residents followed for 5 months 33 Residents followed for 4 months

32 Impact A&E attendance fell Emergency inpatient admissions fell by 36% Length of stay fell by 51% Residents positive Families positive Staff positive (need time, uncomfortable in the beginning)

Leisure Centres Bus advertising JIT is a strategic improvement partnership between the

33 Janette Barrie NHS Lanarkshire Public Awareness Campaign TV adverts on STV & on screens within GP practices Poster Campaign Lamp posts advertising Radio advert for 6 months in Leisure Centres Bus advertising JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

34 Impact in West of Scotland Reached 56% of available TV audience 25% watched TV advert more than 3 times A total of 1.1 million viewers 34 % increase in Power of Attorney registrations in Lanarkshire JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

37 Polypharmacy Reviews JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 37

38 JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 38

39 JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 39

40 JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 40

41 JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 41

42 Think about the Ten Anticipatory Care Supports What is working well in your team and why? What needs to change and how? Who can help general practitioners lead that change locally and nationally? JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

43 Integration JIT is a strategic improvement partnership between the Scottish Government, NHS Scotland, CoSLA, the Third Sector, the Independent Sector and the Housing Sector 43

PACT Patient experience and Anticipatory Care Planning Team. Dr Eleanor Halloran Consultant Liaison Psychiatrist Edinburgh

PACT Patient experience and Anticipatory Care Planning Team Dr Eleanor Halloran Consultant Liaison Psychiatrist Edinburgh Project proposers Dr David Caesar Dr Carl Bickler Clinical Director GP Clinical