Integrated Care theme / Long Term Conditions priority

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1 Integrated Care theme / Long Term Conditions priority Professor Ruth Chambers OBE Clinical lead for LTC priority/clinical lead for Flo telehealth exemplar of Integrated Care

2 WMAHSN Integrated Care & other themes and priorities Integrated Care Adoption & Diffusion Long Term Conditions Education & Training Wealth Creation Digital Delivery TECS Clinical trials Mental health Drug safety

3 Opportunities The NHS is one of the best places in the world to test innovations that involve staff, technology and funding We must combine different technologies and ways of working to transform delivery of care (primary care/all health & social care settings) The information revolution is changing the way patients can engage in their own healthcare 3

4 The Future: ICare Social Care Community Care Primary Care TECS General Hospital Specialist Facilities 4

5 Technology Enabled Care Services- Our ambition NHSE s ambition is to create the right commissioning environment that supports and encourages the innovative use of technology to improve health outcomes and deliver more cost effective services 5

6 The challenge Opportunities Our ambition What commissioners want Commissioning for outcomes Unlocking the potential of TECS 6

7 The challenge Opportunities Our ambition What commissioners want Commissioning for outcomes The commissioner s challenge 7

8 Newark and Sherwood Integrated Model of Care for Long Term Conditions Workforce Development, Training and Education Level Public Health Population wide Prevention Disease awareness campaigns Social marketing Education Health promotion Schools 1 Smoking Cessation, Health Promotion and Self Care Low RISK / Complexity 21% - 100% Proactive Self Care Support and Management in Primary Care Risk score recorded and reviewed annually Active Case Finding Disease Register Accurate diagnosis Information Prescriptions Care Planning Education relevant to patients needs Disease prevention and Health promotion CPM / PARR Tool for Systematic Risk Profiling to identify risk Patients step up and down as risk profile changes % Proactive Disease Management by General Practice supported by specialist community services and teams Care Planning and individualised Care plan Support to Self Manage Education Programmes Annual Review Specialist Medication reviews Anticipatory Care Remote monitoring via tele health where appropriate % Intensive disease / case management by specialist teams as part of the MDT Telehealth / Telecare Community Specialist Services and clinics with MDT support Care Planning and individual personalised care plan Planned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS HIGH RISK / Complexity 4 Top 0.5% Community Matron / Virtual Ward as part of Multidisciplinary Team (Community Geriatrician, GP, Social Care, Therapists, Rehab, Domiciliary ) Care Planning and individual personalised care plan Disease Specialist Input where required from specialist community teams ( COPD, Diabetes) Telehealth and Tele Care Psychological Support Co-ordinated Social Planned Care hospital admission, proactive Personal Care Navigator / Named Lead in reach and facilitated discharge Special Patient Notes / 24/7 Access to Admissions Avoidance where specialist needed support

9 Targeting TECS at conditions & shared management Multiple Single Preventing

10 Driving integrated care via delivery of best practice care for long term conditions via patient empowerment, integration & innovation Best clinical practice & shared management Improved QUALITY of clinical care Tech 10

11 The Advice & Interactive Messaging (AIM) programme national rollout March September 2014 Uses a simple telehealth system ( Florence or Flo ) to help patients to take responsibility for the monitoring and shared management of their own condition, treatment, or lifestyle

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13 Evidence of effectiveness published in: BMJ open access 13

14 Techniques employed for behaviour change via Flo: individual feedback on personal health measures social support Flo information on consequences of behaviour information on tailoring behaviour tailoring selected messages to patient, timing, frequency goal setting (behaviour, outcomes) relapse prevention follow up prompts clinician overview giving assurance, titrating treatment prompted self monitoring of behaviour (Free C, Phillips G, Galli L et al. The effectiveness of mobile-health technology based health behaviour.. PLOS Medicine 2013; 10 (1) )

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18 Hypertension protocols Reminder protocols Smoking cessation protocols AIM01: Diagnosis of hypertension (1 week) AIM04: Inhaler reminders for adults/teens with asthma or COPD (3 months) AIM 06: within first 4 weeks of supported stop smoking service provision (3 months) AIM02: Hypertension monitoring poor control or newly diagnosed (2 months) AIM05: Inhaler reminders for parent of child with asthma (3 months) AIM07: smokers who have quit, end of three months quit smoking service (9 months) AIM03: Hypertension monitoring stable BP (3 months) AIM10: Hypertension monitoring poor control or newly diagnosed for CKD or diabetes and/or ACR 70 mg/mmol (3 months) AIM09: Medication reminder (3 months) AIM08: contemplating quitting but not yet decided to do so (3 months)

19 Usage of protocols Hypertension Reminder Smoking cessation AIM01 AIM02 AIM03 AIM10 AIM04 AIM05 AIM09 AIM06 AIM07 AIM08

20 Registered between March 2013-January patients Evaluation population 425 practices 31 CCGs

21 Primary aims Complete a national roll out of Simple Telehealth ( Flo ) in England Introduce CCGs and frontline primary care practitioners to the everyday use of telehealth through the Flo system Enhance patient experience of shared management of their long term condition(s) via Flo telehealth Secondary aims Illustrate cost-effective application of Flo Raise awareness of the complementary telehealth market for those with more complex needs Raise awareness of a tried and tested method for remote monitoring of long term condition(s) for DES

22 What could be improved Themes What went well Doubt the educational value Time not saved due to patient set-up time and anxieties, problems receiving texts, reviewing data and patients not returning equipment Patients and professional users struggled with Flo and equipment. Cross-cover was problematic Patients not interested or anxious, responses fail/unreliable, no mobile reception. Little benefit over traditional methods, found the system complex/increased work. Wanted direct integration with patient records and to track patients after protocol end More support at the practice level to launch the service and educate staff about its use (e.g. leaflets). Tardy Read code details Puts patients in control of their health Use of appointments Ease of use Acceptability of the system Support using the system Encouraged patients to acknowledge, take responsibility for and feel involved in their health problems/management Saved (nurses and GP) appointments, patients time/inconvenience and resources Patients and professional users found Flo easy Patients are happy, interested, and value the feedback and flexibility. Professional users liked the flexibility of managing patients remotely, being able to send simple messages and having readings on record Valued initial briefing session and demos, case studies, examples of how others are using Flo and the patient pack

23 Implementing Simple Telehealth/Flo drives integrated care across treatment pathways and organisational boundaries to improve patient outcomes care & is cost effective Patients selected on basis of acuity and their suitability for Flo by clinicians Evaluation of Implementation across CCG Clusters (project in deployment stage commencement of patient sign up from Oct 2014) Data within Flo across all clusters - feedback from patients and patient outcomes Data across the North Cluster - health care usage There has been over 14,000 patients across England who have utilised Flo since April 2013 Out of 3000 patients, 96% confirmed they would prefer to use Flo rather than visit their GP Practice Nurse - has given her patients confidence to monitor their own health which in turn has drastically reduced their attendance at A&E or being admitted to hospital, especially for COPD patients. Reduced face to face contacts in surgery to 1/6 th. Main participating Organisations in Clusters - North (6 ), Central (3 ), South (2) (6 CCGs, 3 Acute Trusts, 1 Community Trust and 1 Mental Health Trust) Main project LTCs COPD, asthma, hypertension, diabetes, heart failure, dementia and medication reminders Main participating organisations are also considering the development further protocols e.g. community trust Pressure area management, measuring drainage. Pilot themes/organisations - Pharmacies (medication reviews/integrated care with general practice ), Local Authorities (Carers support - anxiety management ) Network with other AHSNs using Flo (North East & Cumbria/East Midlands) re: gestational diabetes

24 Why do we think this time will be different? Focus on patient outcomes not technology Whole system approach: primary care integral Ability to measure impact and value We know it can be done 24