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 Sectors @jitscotland www.jitscotland.org.uk
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
Number of people in Scotland living with two or more long term conditions
People living in more deprived areas in Scotland develop multiple conditions around 10 years before those living in the most affluent areas
Mental health problems are strongly associated with the number of physical conditions, particularly in deprived areas in Scotland
What Matters to Me Coordination and continuity of care Trusted relationships Accessible information and advice Good communication with, and between, staff
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
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
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
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
Anticipatory Care Planning JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
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
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 www.isdscotland.org/dhip
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 summary Available 24/7 across Scotland in multiple care settings 35000 30000 25000 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 20000 15000 10000 5000 0 Feb Mar Apr May Jun July Aug Sept Patients
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. 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 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 2014. She has had no unscheduled hospital stays in 8 years
NHS Forth Valley KIS/EPC Uploads 12000 2013/14 2014/15 10706 11407 10000 9880 8000 7652 8584 9144 7263 6000 4000 2000 0 April May June July August September October November December January February March
Accesses to ekis 700000 Total 633204 619641 600000 500000 511498 469988 512518 400000 300000 200000 177557 Total 132390 108627 100000 90225 0 17528 32994 9167 2190 3873
Specific Access in one month 60000 50000 40000 30000 20000 Areas accessing ekis Other Areas accessing ekis OOH Areas accessing ekis SAS Areas accessing ekis NHS 24 10000 0
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
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
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
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)
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
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
Polypharmacy Reviews JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 37
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 38
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 39
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 40
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 41
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
http://www.gov.scot/topics/health/policy/adult-health-socialcare- Integration http://www.jitscotland.org.uk/resource/reshaping-care-for-olderpeople-change-fund-building-on-progress-june-2015/ www.jitscotland.org anne.hendry@scotland.gsi.gov.uk @jitscotland JIT is a strategic improvement partnership between the Scottish Government, NHS Scotland, CoSLA, the Third Sector, the Independent Sector and the Housing Sector 43