Transcript The Integrated Service

“An innovative integrated care
pathway delivered to the care home
community"
© the practice plc 2008
Company confidential
Background
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Clinical support to Care Home is variable and inconsistent with
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Multiple GPs
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Poor chronic disease management due to a lack of regular routine visits
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Slow response to urgent calls with a default to calling an ambulance
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OOH services do not always consider the patients best interests due to the
pressures of service delivery and the lack of knowledge of the patient
EoL delivery is erratic dependent on the knowledge and level of engage of
individual GPs and nurses. There is no accountability
Excess Anti Psychotic prescribing and to many medication errors
Inappropriate Hospital Admissions. A&E is over burdened with patients who don’t
want to be and shouldn’t be there
Drug wastage. 8% of medicines are returned
Minimal Specialist Care Home related Training
Due to the sheer number of GPs delivering the service it very difficult to develop
and facilitate integrated working with LASs, Secondary Care, Community Services
Mental Health and Palliative Care services
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Objective of Service
• Provide a patient focused service
• Provide GP services to patients in a primary care setting
• Work with a wide range of care providers to deliver an integrated care
pathway
• Reduce Inappropriate Admissions into secondary care setting
• Reduce medication costs
• Reduce medication errors
• Disseminate knowledge to other interested and relevant parties
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Summary of Service
The Service provides:
• innovative integrated care pathway delivered to care home residents
• innovative technology and processes
• Integrating multiple teams, drawing on their specific expertise from:
 private sector
 primary care
 secondary care
 acute trusts
• delivering a patient focused service
• Identifying and incorporating the patients' wishes, ensuring the patient is:
 cared for
 receives emergency care
 ends their days in the comfort of their home
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Summary of Service.....................contd.
• Capitalising on work that has already been done and building on what
has been achieved in the areas of:
 End of Life
 Medicines Management
 Admissions Avoidance
 Dementia Care
 Chronic Disease Management
• By following best practice and utilising lessons learned from initiatives that
have taken place on a smaller scale with reduced scope, a service is
being delivered that is:
 Benchmarked
 Monitored
 Regularly reviewed and tweaked
 100% compliant care pathway
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The Integrated Service
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24/7/365 Clinical Support
 Regular routine on-site GP surgeries which will include:
o Urgent Needs
o Regular Health Checks
o Managing Repeat Prescriptions
o Resident / Relatives consultations
 Telephone Triage / Urgent visits from the clinical team within surgery open
hours
 OOH Telephone Support from GP outside of core working hours
End of life contract and management
Full GP access to patient record and End of Life contract
Clinical Reviews
Online access to reports, prescriptions and drug information
Efficient prescription ordering process to save significant time
Active reduction in the use of antipsychotic drugs
Training
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Who we are working with
• Integrated working with:
 Care Homes
 Pharmacy Team
 EoL Team
 Palliative Team
 Acute Trust
 LAS
 Geriatricians
 Diabetes Team
 Community Team
 Nutritionist
 Alzheimers Society
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Support and Endorsement for the Service
Support and Endorsements for the service has been received from:
National
• English Community Care Association
• Care Home Groups
• Alzheimers Society
• NHS Diabetes
• Age UK
• NHS End of Life
• NICE
Local
• South Central SHA
• TV HIEC
• Bucks Hospital Trust
• NHS Bucks
• NHS Milton Keynes
• South Central Ambulance Service
• Florence Nightingale Hospice
• Care Home Associations
• Care Home Groups
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Current Status
• Homes signed up
 Milton Court, with 110 residents, started service 3rd May
 Hampden Hall, with 140 residents, starting service July
 Rock House, with 50 residents, starting service July
 Burford House Nursing Home, 50 residents, starting in August
 Fremantle Trust is rolling out service in 6 of their homes,
which have approx. 450 residents, between July and Sept
 On going discussions with :
o Caring Homes
o Four Seasons
o Barchester Healthcare
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Current Status ...............contd.
• Resourcing - recruitment
 Medical Coordinator
 GPs
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Lessons Learned include:
 Initial Assessment of patients conducted by Nurse rather than GPs
 Integrated working with Nutritionists / Dietician
 Engagement with PCTs Pharmacist
• Stand alone unit agreed with NHS Buckinghamshire , which includes
 Setting up own “K” code
 Own clinical system
 Funding
 Registering patients across boundaries within SHA
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Savings
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£33,253 saved within 1st month of service on medication review patients from Milton
Court
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21 med changes to more cost-effective items (many liquid med conversions to
tablet form)
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50 meds discontinued
During 2010 - 912 episodes generating 519 spells at a cost of £1.27m. Only 149 were
elective the rest were emergency.
The top 6 admissions and spends are;
1.
Chronic Renal Failure
2.
Good of Fracture neck of Femur
3.
Urinary Tract Infections
4.
Influenza and pneumonia
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Acute Renal failure
6.
Lower respiratory
If we manage to save a quarter of these costs during 2011, we will save the NHS
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£317,500
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