Integrating Care for Neurology Dr Mo Ali Clinical Director Whole - - PowerPoint PPT Presentation

Integrated Care Programme

Integrating Care for Neurology

Dr Mo Ali Clinical Director Whole System Integrated Care Neuroscience Strategic Leadership Group

Integrated Care Programme

Overview

• Initial journey
• Implementation
• Next steps
• Learning lessons

Integrated Care Programme

Initial Journey

Integrated Care Programme    1. Patient Registry

• 2. Risk

Stratification

• 3. Care

Pathways

• 4. Work

Planning

• 5. Care

Delivery

• 6. Case

Conferencing 7.Performance Review

• HES data (possibly risk strat too); UTIs, falls, respiratory infections, pain management, skin management
• Social indiicators: level of care (current changes to criteria from 50m down to 20m unrealistic if relapse – impact on DLA, care funding)
• Employment (905 within 10 years are not working)
• Review at a large enough level to offer support at secondary care level (not Queens Square)
• Work through the numbers to establish right size
• Web based “online clinics” similar to neurolink
• Use 111
• As much as possible in the community
• Initiation only in hospital and monitoring in the community
• Initial care plan in secondary care
• Subsequent in primary care with access to a hub site
• Activate care plan for quick access
• Post – diagnosis: need continuity AND rapid access; potential use of personal budgets
• Community package of care based on rehab and drug treatment in the community
• Provide “hub of continuity” and within “turbulence create stability” based on anticipatory care plans
• Relapsing – remitting (and secondary progressive), primary progressive
• Focus on just relapse
• Use of disease modifying drugs
• <65 who are employed (no support and can spiral down)
• MS and MS with relapse
• Exclude Clinical Isolated Syndrome (CIS)

1st Meeting: Definitions

Initial Journey

Integrated Care Programme 1. Patient Registry 2. Risk Stratification

• Defined as those diagnosed with MS up to 160/100k, NWL = 3,520 (0.16%), 440/CCG area
• Consider medical, psychological and social components

Highest Relapses

Confined to bed or wheelchair Walks with aid (<5 yards) Walks unaided (≥330-550 yards) Fully ambulatory Death

Highest Relapses

• Last relapse
• Worsening symptoms
• New symptoms

Emerging view

• 3. Symptom relapse :
• a. Infection exacerbation
• b. True relapse
• 1. Asymptomatic
• 2. Symptoms: maintenance

2nd Meeting: Expansion

Initial Journey

Integrated Care Programme 1. Patient Registry 2. Risk Stratification

• Defined as those diagnosed with MS up to 160/100k, NWL = 3,520 (0.16%), 440/CCG area
• Consider medical, psychological and social components

3rd meeting: Focus

• Hospital, MH, practice, LA screened
• 3 axis of need triangulation
• Assume gradual progression through relapse
• Trigger of care plan = relapse
• 85% Relapsing – remitting = 2,992

(50% secondary progressive = 1,496)

• 10% primary progressive = 352
• 5% progressive relapsing = 176

Background Potential Model

Community Ward View Patient 3 Axis Stratification Very High Risk (0.5%) = 18 High risk (0.5-5%) = 158 Moderate risk (5-20%) = 528 Low risk (20-50%) = 1056 Very low risk (50-100%) = 1,760 Very High Risk (0.5%) High risk (0.5-5%) Moderate risk (5-20%) Low risk (20-50%) Very low risk (50-100%)

• Progressive
• >1 relapse
• Motor
• Sensory
• Both
• Infection
• ….

Medical Psychological Social

MS budget (NWL) Each patient = £19,726 › Equipment £5,966,753.89 › Services £39,731,770.08 › Medication £23,738,749.16 › Costs not included £255,309.03 › Overall MS budget £69,437,273.13

• 1. MS Society have SUS
• 2. Harrow as a focus

Initial data set

• 1. Self – reported ‘I’
• 2. SUS
• 3. MS specific (?)

Initial Journey

Integrated Care Programme

Choosing Harrow

• Harrow: GPs, 3rd sector, community and 3 acutes (!)
• Move from fragmented to integrated delivery for patients
• Consider steroids in the community model (oral)
• Pick one area to pilot
• Harrow: max. 368 (Margaret: 200-250 cases); 8 practices with >9 MS
• 35 GP practices total, MS Therapy centre, Community Nurse
• Northwick Park linked to NHNN
• Central Mid linked to Imperial (Charing X/St Marys)
• Use ICP infrastructure: online communication, meetings and 111

Initial Journey

Integrated Care Programme

• 250+ patients
• 1 MS Therapy Service

Historic Model of MS in Harrow

• Established diagnosis: care plan by GP practice
• Care plan linked to 111 and UCC/A&E across NWL
• Acute access requires initiation of patients rescue therapy
• r infection exclusion by primary care then involve nurse
• Referral to nurse for assessment and consider steroids
• (?)Steroids in the community
• Referral made to secondary care
• GP suspects and refers OR A&E
• Investigations Northwick or Central Middlesex
• Diagnosed at NHNN or Imperial and started on treatment
• Community nurse (Ealing) at NPH supported by another trust
• Access through assessment and remote treatment

Existing Pilot Model

• 35 GP practices
• 1 MS nurse
• 1 community provider
• 3 acute trusts

111

Reporting in 1. …. 2. …. Care Plan 1… 2..

Initial Journey

Integrated Care Programme

Implementation

Integrated Care Programme

• 8 practices with >9 patients
• Need to upskills

Existing case load

• Direct access (nurse/consultant)
• Consider MDG frequency
• MDG partners (MH,SS, …)
• Care coordinators

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NPH Edgware WIC RNOH 1 3 2 4 5 3 6 7 8 9 10 11 12 13 14 15 18 17 20 19 21 22 23 2425 26 27 28 29 30 31 33 32 34 35 36 37 27

8 practices with >9 patients

• Bacon Lane Surgery = 10
• Elliot Hall Surgery = 9
• Enderley Road = 14
• St Peters Medical = 9
• Northwick Surgery = 10
• The Pinn Medical Centre = 17
• The Ridgeway surgery = 10
• The Stanmore Medical Centre = 11

Implementation

Integrated Care Programme

MS Model in a Slide

MS Registry

Create registry at outset Review population Set baseline for activity with a starting score

Case management

Review risk, HSCC & GP Create MS Care Plan, give urine dipstick and script Multi-provider input

Ongoing reviews

HSCC, GP + MS nurse Regular review throughout year MDG is the learning set

Current Model New Model

Integrated MS Pathway

Patient initial diagnosis in hospital (NHNN

• r Imperial) and treatment started

Review in community with secondary care support at Northwick Relapse assessment with return to

• riginating hospital, no GP involvement
• Hospital diagnosis
• Review in

community

• Relapse

assessment in community or hospital setting

Patient Level Practice Level Provider Level BIRT 2 Video-Conf 111 Implementation

Integrated Care Programme

MS Multi-Disciplinary Group (MDG) Pilots

• 3 meetings:
• GPs
• Social Worker, 3rd Sector group, Psychiatrist
• Neurology consultant, Neurology Specialist Nurse
• Community MS Nurse
• Approx 18 patients reviewed in detail
• Defined learning needs
• Exhausted reviews and looking to move to PD/Epilepsy
• Break to complete education material before next steps

Implementation

Listening

• First meeting

exciting, new

• Second,

similar pattern

• Third,

exhausted cases Soft Measures

• Failures –

trainee role

• Mobile

numbers

• Patient

transfer to GP

Integrated Care Programme

Next Steps

Integrated Care Programme

Providers System Commissioners

• Model of care plan is

robust and affordable

• Implementation plans have

been clearly communicated and enacted

• Model of care is aligned to

expected outcomes

• Plans are person-centred

and co-produced

• Commissioner

expectations for outcomes are aligned and have been clearly communicated to providers “Shadow” Focus on planning, implementation and

• utcomes
• Performance

management systems and capabilities are in place to manage delivery

• Continuous improvement

and learning systems established

• Organisations are ready

to change

• Performance

management systems and capabilities are in place “Shadow plus” Focus on governance and capability-building

• Strong financial and

performance management capabilities used to manage risk and innovate model of care

• Commissioner and

provider incentives are aligned to deliver highest quality of care at best value for money

• Systems consolidated to

commission at scale for population groups Full risk sharing Focus on execution with full ACP financial responsibility

• Governance processes

allocate funds effectively and hold partners accountable

• Procurement capabilities

in place

• ACP meets procurement

requirements

• Joint commissioning

responsibilities and processes are clearly defined, and capabilities exist to meet them Real budget with low risk Focus on execution and finances Forward-looking assessment to evaluate readiness or limitations Incremental checks required as the ACP adds population groups or functions Full assurance checkpoint to assess risk management capabilities = Focus of 15/16

Whole Systems Integrated Care NWL

Next Steps

Integrated Care Programme

Harrow Virtual Ward Current State

Place Based Provision Teams

• MDG Chair Lead
• Consultant
• Navigators
• Nurse Case Managers
• MDT: SW, Psych, DN, MH,

Palliative Care, pharmacist

Future State

Place Based Provision Teams

• Senior GP Support
• GPwSI in Older Adults
• Consultant supervision
• Navigating Ward Clerks
• Pharmacist Case Manager
• MDT: SW, Psych, DN, MH,

Palliative Care, pharmacist

Key Steps

GPwSI Pharmacist Ward Procedures

• JDs
• Recruit
• Training programme
• JDs
• Recruit
• Training programme
• Model
• Standardise
• Roll out

1 2 3

Current State of Virtual Ward

Next Steps

PD & Epilepsy Across Virtual Wards

Next Steps

• Videos
• VW

embed

• Review PD

& Epilepsy

Integrated Care Programme

Learning Lessons

Integrated Care Programme

5 Key Lessons

Learning Lessons

Engagement Governance Prepare ( and part mobilise) Launch (fail fast and learn)

▪ Right People ▪ Build consensus ▪ Listen ▪ Flexible (1:1) ▪ Focus on detail ▪ Re-engage ▪ Celebrate successes ▪ Acknowledge failures ▪ Look forward ▪ Silo to Joint accountability ▪ Keep patient centred ▪ Set measures of success ▪ Test hard and soft ▪ Keep equality ▪ Re-test (e.g. steroids) ▪ Re-visit agreements ▪ Plan against long term ▪ Build confidence

Sustain (and seed) Culture

▪ Air attitudes and differences ▪ Set shared vision ▪ Check and clarify roles ▪ Move to local ownership ▪ Challenge and check views ▪ Correct misunderstandings ▪ Consider changing people ▪ Integrate with local beliefs ▪ Build ‘part of furniture’

Information

▪ Start simple ▪ Provider to provider ▪ Keep eye on PID ▪ Review/audit details ▪ Keep clear logs ▪ Stay open around financials ▪ Stay data driven ▪ Set an aligned strategy ▪ Retain healthy cynicism

Support

▪ Over estimate input ▪ Ego less individuals ▪ Break hierarchies ▪ Stay nimble ▪ Re-apply to greatest need ▪ Direct to keep focus ▪ Review against infrastructure ▪ Balance optimum/minimum ▪ Stay credible

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