Integrated Care & the Preventative Agenda Joanne Gutteridge Senior Commissioning Support Officer Dudley CCG

Integrated Care & the Preventative Agenda Joanne Gutteridge Senior Commissioning Support Officer Dudley CCG

Overview of presentation Setting the context Drivers for change New commissioning framework & model of care Risk stratification Use of Technology Key preventative initiatives Future aspirations

Setting the Context The Long Term Condition Burden Chronic disease is most common cause of death and disability >15 million people have a long-term condition Huge drain on healthcare resource - 50% GP appointments - 64% outpatient appointments - 70% inpatient bed days - est 18% are in receipt of state funded social care Prevalence increases with age - 50% people aged 50-80% people aged 65

Setting the Context Current service provision Service provision reactive rather than proactive Duplication within the system Difficult to access and navigate Increase support for self-management

Drivers for Change - Workload in primary care - Financial flat line for NHS for next 4 years - Directive to shift NHS spend to social care - Demand on acute sector - We cannot stay the same - Changing demographic and population needs

The Strategic Context Dudley Health & Wellbeing Board has developed five priorities in its Joint Health and Wellbeing Strategy, one of which is:- integrating health and care services to meet the needs of the changing Dudley borough demography The strategy also identifies a further priority:- making our neighbourhoods healthy - by planning sustainable, healthy and safe environments and supporting the development of healthenhancing assets in local communities These two key priorities are brought together in our Primary Care Strategy.

A New Commissioning Framework Planned Care Urgent Care Children Mental Health Specialist Placements & Recovery Learning Disabilities Preventative Care Reablement Care Older People

Integration - A New Model of Care

A New Model of Care

Risk Stratification Benefits of the ACG System

Risk Score- Contributors

ACG Predictive Modelling Future costs Future hospitalisation Future high medication use Co-ordination markers The premise behind the creation of the ACG Coordination Markers is that individuals receiving poorly coordinated care have been shown to have worse clinical outcomes and higher medical expenses than individuals who are being provided coordinated care. Treatment gaps

Risk Profiling DES NHS England specification for localisation and implementation by CCG Specification clinically led Prescriptive around the Virtual Ward MDT process Encourages locality based collaborative working

Remote patient support Use of Technology Ageing population disease prevalence increasing Evidence base Kings Fund, WSD Adoption to be part of a fundamental service redesign integrated model Supports self-care, independence and well-being What is currently being implemented in Dudley? Remote Monitoring DES

Use of Technology Enhance patient care Use of IT in community nursing Shared care record

Prevention Agenda Early identification, diagnosis and treatment Keeping well for longer Empowerment to self manage Avoid unnecessary unplanned hospitalisation

Elderly care pathway Rising emergency admissions to secondary care particularly from the cohort of those aged 75s combined with prolonged length of stay amongst frail elderly people is both operationally and economically unsustainable.

Emergency Admissions Age Breakdown Emergency admissions for over 64s make up 44.6% of all emergency admissions for Dudley CCG 75 years and over make up nearly a third of the total emergency admissions Over 64s emergency Admissions cost Dudley CCG over 32.5 million last year. This is over 60% of the total cost for all emergency admissions

Evidence base for redesign The vast majority of admissions (11,332) for over 64s are via ambulance (83.37%) As would be expected LOS is higher for the over 75s than the 64-75 age group. 6,338 of the 14,225 admissions are for stays of 2 days or less. Infections as a whole are the dominant reason for an admission (UTI, chest infections, cellulitis).

Frail Elderly pathway New Community Rapid Response Team for Frail Elderly : 7 days a week 08.00-22.00 Focus on assessment and management of the frail elderly The team will be integrated with the MBC to provide urgent social care packages Objective to reduce 1000+ non-elective admissions per year Handover process with existing community teams for on-going management and support Further development of community IV pathways to support the model

Diabetes At Risk Inclusion within Diabetes LES Commissioning of Website Production of reducing your risk workbook Promotion through social media GP TV link

Diabetes At Risk Website

Cardiology New Model of Care Primary care based diagnostics Single point of access Specialist based triage Diagnostics and management plan One-stop cardiology clinics

CCG Local Quality Premiums Atrial Fibrillation - undertake 600 reviews patients are currently have a CHADS2 score >1 and are not receiving the appropriate anticoagulation Hypertension - increase the population on the hypertension QOF register by 1% (547 cases)

In addition NHS Health Checks Programme Expert Patient Programme Personalised Care Planning - diabetes - COPD/Asthma - Heart Failure - EOL

Future Aspirations Increase psychological support Self- Care Prescription Prevention Dashboard

Questions?