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Integrated Care – Where next?

Sasha Karakusevic. Integrated Care – Where next?. Starting high, aiming higher. We have achieved substantial improvements for our community and receive positive feedback from patients and the public

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Integrated Care – Where next?

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  1. Sasha Karakusevic Integrated Care – Where next?

  2. Starting high, aiming higher We have achieved substantial improvements for our community and receive positive feedback from patients and the public Both the Care Trust and Foundation Trust were finalists in the HSJ PCT/Acute Trust of the year in 2009 But we know we can and must do better

  3. Q2 BCBV sets baseline

  4. The community journey • Whole district trust 1992-7 GP fund-holding 2000 Integrated Care Network plan • Torbay Care Trust 2009 Integrated Care Organisation pilot

  5. Key lessons and hard choices • Partnerships • Innovation • Managing the system • Nurses and workforce • Diagnostics and decision support • 24/7 versus local • Facilities, equipment and co-ordination

  6. What has Mrs Smith experienced? 1991 Working in Brixham • Her mother needs a hip replacement, spends 2 weeks in Exeter having waited 12 months for surgery. Has a stroke 1 month later and spends 30 days in Torbay and 60 days at Paignton before discharge to a nursing home for 6 months. Dies. • Retires. Husband has MI, waits for 3 weeks in hospital before transferring to London for surgery. • Husband develops heart failure and dies 18 months later following 4 admissions

  7. What would happen today? • Mother has hip replacement 3 months after seeing her GP. Date arranged to enable holiday with daughter pre-op. Enhanced recovery and VTE prophylaxis mean mum home 3 days post-op without complications. • Husband has chest pain. Calls 999 and has angioplasty 74 minutes later. Changes lifestyle. • Couple living happily and enjoying grandchildren.

  8. The new challenge No change! Add £13m £82 each Say £500 per family And this in only 25% of the health budget

  9. Needs are changing 10-19 20-49

  10. What should we be dreaming about today to meet this challenge ?

  11. Imagineering b. 1928, lives forever

  12. Integration is part of the solution Excite, delight, simplify

  13. Experience is growing

  14. Virtual Pooled Budget for Older Peoples’ Care • Assistive Technology to support COPD patients • RACE Clinics • Emergency Admission to Hospital for complex conditions • Community Hospitals Medical Evaluation • COPD/CCF/Dementia in Nursing Homes • Emergency Care Practitioners supporting falls • Primary & secondary care Medical Model • Hospital Discharge • Co-ordinators • Orthopaedic Pathway • End of life care Training

  15. Pro-active care for Mr and Mrs Smith • Self care when possible • Tele-health support for high risk periods • Packages of care optimised to maximise benefits • Pro-active intervention when markers indicate increasing risk

  16. And for the care team • Investments to optimise capacity of local care settings and teams • Efficient support to optimise decision making and promote flexibility • Real time feedback of results and alerts accelerates improvement in outcomes • Virtual activity • Specialists support frontline teams

  17. What does this means for Mrs Smith? • Getting more frail and forgetful. Husband has diabetes and some heart failure. Daughters live in London and Scotland Local support network in place (based in local nursing facility) to respond to issues detected by home monitoring system. Mr Smith has not needed to visit practice or hospital due to real-time monitoring and medication management system. Daughters can support care through video link and access to shared records

  18. What does it mean for us?

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