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Currently managing of 10.8 million lives across the UK & Canada. Integrated Care . What’s in a name……. Today, 175 definitions of “Integrated Care”. (Kings fund). Integration [definition]: Person centered coordinated care* (National Voices)
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Currently managing of 10.8 million lives across the UK & Canada
Integrated Care • What’s in a name……
Today, 175 definitions of “Integrated Care” (Kings fund) • Integration [definition]: Person centered coordinated care* (National Voices) • “My care is delivered from people who work together to understand me and my carer(s) needs, and coordinate services to achieve my best outcome”
Innovation driving integration? = Interoperability Integration
Interoperability: diverse systems working together 3rd sec LA Data Comm. System Vol. Sev. Hospital PAS GP System Moving DATA between services & settings
Integration: Person centered coordinated care Moving PATIENTS between services & settings
Strata connects the entire network of providers; ensuring the patient’s journeyis planned & monitored; creating a truly shared approach Moving PATIENTS between services & settings
…so many care pathways, what is safe? Religious Support Long Term Care Social Care Addictions Age Concern Village Support A&E Health Visiting Socialization MAU End of Life Hospital Rapid Response District Nursing Bereavement Counseling Mental Health Deal or no deal ? Community Services PT OT Assisted Living
No, very much within the ‘Art of the Possible’! • ‘Process’ defines ‘outputs’ - no panacea • Need a framework that underpins local best practice process • Clinically lead, operational driven, & supported by IT • Bespoke needs of patients • Local Best Practice process & service delivery • Dynamic: expect change • CI culture: CHC/DST, reduce readmissions, social housing, anti-coagulation, mental health
System wide care coordination value proposition: planned, transparent, consistent = QIPP
NHS IMAS: 8 principles for patient flow Early senior review. Daily senior review. Focusing on discharge. Continuity of care. Matching capacity to demand and reducing variation. Internal professional standards. Ambulatory emergency care. Managing patient flow streams.
Making Integration Happen: Kings Fund Developing integrated care means overcoming barriers between primary and secondary care, physical and mental health, and health and social care to provide the right care at the right time in the right place. Innovate in the use of commissioning, contracting and payment mechanisms and use of the independent sector
Patient Flow through the entire system! CCG’s Local Authority Community Services Volunteer Services
System Wide Collaboration RESOURCES MATCHING, CAPACITY, PULLING & PUSHING, Status intervals, messaging, thresholds / breach driving KPI’s
Actions during the patient journey / hand off facilitated by Strata Access ALL options on patient hand-off DDA (2003) replace inefficient transactions Decision Support Increasing plurality of Provision Transactional progression of patient hand-off Admission criteria bespoke to local service Dashboard tasks & waitlists Real time Capacity a fx of Process Interval time benchmarked
System-wide access drives utilization across the entire health ecosystem A&E / Hospitals Patient Assessment / DST GP’s CFT / Social Care / Volunteer/ 3rd sector Business Intelligence
The Challenge: reduce time wasted on manual communication / paper process
The Solution: a common referral & automated process to direct clinicians to appropriate services
DTOC reduced 23% overall, driven by 63% across ‘waiting for completion’ Assessments ‘waiting for completion’ More than halved
But even more so: collaboration of teams, resulting in outcomes we can ALL be very proud of!
Across the Commonwealth, dramatic results in reduced DTOC! Over the last 4-year ends, patients waiting in hospital beds for more appropriate care levels/locations has trended down to a low of 27 clients over 2000 beds! ALOC days are now <2% of total acute beds -Nancy Hughes, Director CHR
Patient choice & satisfaction increased! • A demonstrable increase from 60% to 84% of first placements to a location / geography of patient choice!* *Auditor General Alberta Calgary Annual Report 2002/2003
International Reference: Internal Strategy Internal Strategy / Training Video RM&R today – z patient & family’s perspective