North East Leicester PbC Cluster Extended Integrated Care Team

1. North East Leicester PbC ClusterExtended Integrated Care Team Dr Nitin Joshi – GP & Project Lead Clinician Tracey Shepherd – Locality General Manager Michelle Beasley – Project Manager, Personalised Care Plans

2. HypothesisDoes a whole systems approach to integrated care lead to better quantative and qualitative outcomes?

3. NEL Commissioning Group The wider context • 7 Practices • Population 44,777 • 16.1% Patients Over 65 vs. PCT 11.6% • Disease Prevalence rates higher than PCT average • CHD • Heart Failure • Stroke • Hypertension • COPD • Asthma • CKD

4. Timeline • November 2007 – Unique Care Pilot • March 2010 – Presented Business case to expand project • July 2010 – funding received and EICT Project commenced • August 2010 – Link with QIPP LTC workstream

5. SIMPLE SYSTEMS COMPLEX SYSTEMS Need individual care plans ‘mono’-morbidity Multi-morbidity Good mental health Mental health complications Well defined groups Poorly defined groups Defined interaction with secondary care Poorly defined interaction with secondary care ‘one size fits all’

6. SIMPLE SYSTEMS COMPLEX SYSTEMS Need individual care plans ‘mono’-morbidity Integrated team Multi-morbidity ‘one size fits all’ Good mental health Mental health worker Mental health complications Well defined groups Risk stratification Poorly defined groups Defined interaction with secondary care Acute care group primary care physician Poorly defined interaction with secondary care Personalised care plans

7. Patient Pathway All patients of NEL cluster Best practice, Map of Medicine and Medicine Management Risk Stratification Tool Pilot and other intelligence to identify patients at risk patients Extended Integrated Care Team GPs Practice Nurse Social Workers Community Matrons Mental Health Worker District Nursing UHL (Acute Sector) Proactive Admission Management & Discharge Planning Appropriate Treatment Early Discharge Pathways In reach nurse

8. The Business Case Focus 2008/09 NEL Cluster Higher than PCT average spend for: • Total Non Elective Admissions • Excess Bed Days • Prescribing • The KPMG 6 identified conditions • Cellulitis • Lower Respiratory Tract (without COPD) • Lower Respiratory Tract (with COPD) • Congestive Heart Failure • UTI • Dehydration

9. Handbookexample

10. Handbook example

11. Handbook example

12. Case and Load Management Meetings

13. Activity Targets

14. Evidence so far Summary - Non-Elective admissions against Target for 6 Priority Conditions for First 6 Months ( April 10 - September 10) All Providers.

15. Evidence so far Emergency non-elective admissions

16. Evidence so far

17. Personalised Care Plans • Patient held & led record • Communication Tool • Holistic approach • Support for self management • Developed by a stakeholder group • Excellent ‘fit’ with the pilot • QIPP programme helped gel together

18. What they say Anne Forde – Adult Social Care “Personalised care planning is the only way to work as it puts the individual at the heart of their support. It focuses the workers on the individuals, goals, wishes feelings, needs and what's important to that person to support them and enable well being”. Zoe Harris - Community Health Nursing Lead “My experience of PCP’s for level three patients is that they can be an effective way to ensure quality care for individuals with LTC’s particularly when they include the patients own self management plan when they experience an exacerbation of their condition and also to record their wishes for end of life care”. Mark Pierce – Commissioner NHS Leicester City “Personalised care plans have great potential to contribute to improvements in patient outcomes. They can offer commissioners a window on the workings of the services they commission.  They also offer an insight into how patients experience their illnesses and as such can be of interest to any commissioner.”

19. What they say Diana Osbourn – patient “It is fantastic that my wish to have more control and responsibility over management of my Long term Condition has at last been acknowledged and that I will be able to really work in partnership with my GP & Health Specialists to prioritise what is important to me” John Cook – patient "I am sure that the joined up thinking, at the heart of this project will help NHS become more effective and efficient benefiting practitioner and patient” Dr Maini, EICT Project GP “A cohesive way of working that benefits patients and health professionals alike” Patient “Less time wasted on duplication and reducing my visits to the GP/Doctor, saves time & money for me & the NHS - it’s a winner all round! “

20. What they say Integrated Care Project “Excellent to see how joined up thinking and working can save £’s as well as lives – and that it is actually working!” Project Lead – Personalised Care Plans The reaction from patients and voluntary groups especially has been one that “We are really ready for this, and are looking forward to help manage our conditions the way that works best for us, working in partnership with our key workers “ Social Worker Bhavna Maher EICT Project “Services will benefit greatly if health and social care professionals work in partnership” ’ ’

21. Where Next • Handbook • Web pages/ YouTube • Risk Stratification • Recruitment of MHNS • Recruitment of 2 In Reach Nurses • Project survival in the current changing climate

22. HypothesisDoes a whole systems approach to integrated care lead to better quantative and qualitative outcomes?