ProMISE P ro active M anagement of I ntegrated S ervices for the E lderly

1. ProMISE Proactive Managementof Integrated Servicesfor the Elderly Academic half day: Patient Self Care

2. The difference we are making “Having been hospitalised in the PRUH four times, I was feeling neglected at home when I was contacted by the visiting matron, Helen. She helped me enormously with her professional support. Congratulations to whoever initiated this marvellous scheme!” Thank you letter sent to ProMISE programme team. Academic half day – Patient Self Care

3. A positive shift Since the introduction of risk stratification and case management there are encouraging signs of a reduction in admissions of Bromley residents aged 65 and over (both planned and unplanned). Academic half day – Patient Self Care

4. Facing up to challenging demands • Increasingly challenging demands on our services from an ageing population with ever more complex health needs mean that we need to find new ways of working together across health and social care. No change is simply not an option. • We have developed a clear vision for the future of health and wellbeing for our elderly residents which focusses on improved care. Both patients and practices will benefit from our integrated care programme. Academic half day – Patient Self Care

5. Our range of services includes • Risk stratification • Ongoing integrated care pilot • Integrated locality community teams • Active care planning • A comprehensive falls and fracture prevention service to be delivered in partnership with King’s and Bromley Healthcare • Simple home diagnostics and telehealth initiatives (FLO) • Expert patient programmes • Support for more timely diagnosis in nursing and residential homes • Enhanced end of life services through the St Christopher’s Group. Academic half day – Patient Self Care

6. Integrated community teams • Six integrated community teams across the borough, aligned to GP practices covering a population of approximately 50,000 residents each • Each will have a core team including: clinical team lead, local coordinator, community matron, district nurse, physiotherapists, occupational therapists, nurse rehab assistants, Healthcare Assistants (HCAs) and physiotherapy assistants • Teams will develop close working relationships with GP practices as well as with community mental health, community pharmacists, social care, end of life care and other specialist community nurses and services. Academic half day – Patient Self Care

7. Falls and fractures service • A comprehensive falls and fractures service is currently being designed with Bromley Healthcare and will go live in January 2014 • This will be a specialist service for all older adults who have fallen or who have been identified as being at risk of falling and is also available to those identified at high risk of osteoporosis and fragility fractures. • The service will provide education to Bromley residents on falls prevention, investigate reasons for a fall and provide interventions as appropriate through exercise/balance classes and home assessment • Bromley Healthcare is also exploring opportunities to work with Bromley Mind to provide classes for patients with dementia. Academic half day – Patient Self Care

8. Florence simple telehealth system (FLO)  • Proof that telehealth doesn’t have to be overly complicated, this easy to use (award-winning) system uses mobile phones to help people with long term conditions for improved self care • Can help communication between clinician and patient through a series of scheduled interactive text messages (e.g. motivational texts for smoking cessation or to help lose weight) • Patients submit vital signs data (such as blood pressure readings) to clinicians using their own phones via a text message and get appropriate advice back • Provides additional information to help with clinical decision making • 30 practices have already expressed an interest in trials and a number of protocols are being tested. Academic half day – Patient Self Care

9. Enhanced end of life services • The End of Life service will be provided by the St Christopher’s Group and builds on existing services with a dedicated End of Life Care Coordination Centre providing out of hours advice and: • Nurse specialist assessment, including advance care planning conversations • Key workers • Coordinate my care registers • Three monthly reassessment • Marie Curie nursing • Coordinate medical equipment • Support links in to community services for integrated approach • Rapid response to patients whose conditions have changed • Provide personal care services for up to six weeks for PRUH discharges. Academic half day – Patient Self Care

10. Practice Liaison Officers (PLOs) • A new role in UK general practice which develops the PLO in general practice to support vulnerable patients in anticipation of their needs • 39 out of a possible 46 practices in Bromley took part in trials (88%) • Benefits for practices and health services include less administration for GPs and better communication for all staff • Benefits for patients and carers include better relationships with vulnerable patients and practical suggestions such as reminding elderly patients to avoid missed appointments • The PLO role can support local incentives to develop and manage care plans for vulnerable patients at risk of hospital admissions and falls, together with identification and support for carers through a ‘carers’ register’. Academic half day – Patient Self Care

11. What will this mean for your patients? • Feeling more reassured because their needs and the needs of their carers have been shared with the professionals involved in supporting them • Knowing that decisions about their care will be made with them and made more quickly • Knowing their personal goals will inform these decisions and they will have more control over their health, helping them to live a full and independent life • Making fewer trips to the GP and hospital. Academic half day – Patient Self Care

12. What will it mean for you? • Feeling part of a more defined team of health and social care professionals and placing a greater emphasis on prevention and self care • Enjoying better access for healthcare professionals to a wider range of community based services and working more closely with the voluntary sector • Having time to deal with the most complex patients and feeling more in control of workload • Sharing skills and knowledge with colleagues and using regular feedback to improve our services Academic half day – Patient Self Care

13. Making a difference together • For more information about the ProMISE programme and the difference we can make together contact: • Dr Mandy Selby and Dr RuchiraParanjape • Paul White, ProMISE Programme Director • Kate Dawes, ProMISE Programme Manager Through the ProMISE office on 01689 880 583 ProMISEProactive Management of Integrated Services for the Elderly Academic half day – Patient Self Care