Royal Free London

NHS Foundation Trust

Our Integrated Care Journey

Dr. Alexandra Wu

Clinical Director

Service Transformation

The Royal Free

Integrated Care Journey

Scope and Contents

• What is integrated care?

• Why do integrated care?

• What is involved?

• How did we do it?

• What did we learn?

• How did we evolve from our learning?

• Summary and conclusions

• Questions & Answers

The Royal Free• Licensed as a Foundation

Trust since April 2012

• Merged with Barnet and

Chase Farm Hospitals

(July 2014)

• £1 Billion turnover

• 10,000 full-time staff

• 1100 beds approximately

• Teaching hospital and a

tertiary with district

general function

1. What is integrated care?

• Meeting the needs of individuals by flexible and

seamless working across multiple organisations to

deliver optimal and personalised care whether in

hospital or at home

• This is a collective responsibility between the

primary and secondary sectors.

2. Why do integrated care?

• Current economic environment for the NHS

• QIPP - Imperative is to achieve ‘best in class’

clinical productivity (length of stay, re-admissions,

excess bed days)

• Clinically led pathway redesign focused on patient

cohorts

• Results in length of stay reductions and admissions

avoidance

3. What’s involved• Two innovations in September 2010

– Post Acute Care Enablement (PACE)

– Triage Rapid Elderly Assessment Team (TREAT)

• Patient cohort

– Complex, elderly patients

– Urgent care division

• Department involved

– Health Services for Elderly People (HSEP)

– 3,200 emergency admissions/year, 40% of acute take

– Chronic long-term conditions, care homes, variable acuity

• Aim to deliver a different model of care

– Reduce admissions

– Early support discharge

– As safe and as high quality but in a lower cost setting

• Funding and resources

– Closure of 18 bedded acute medical ward to re-direct funding for the innovations

– Appointed Dr. Alexandra Wu as clinical champion and Kam Karilai as project

manager under the direction of Katie Donlevy, Director of Integrated Care

4. How did we do it?• Brainstorm with multi agencies in May 2010

• Build relationships, establish capabilities and facilities available

• Identify patient groups and wards

• Map out patient’s pathway, define process and logistics

• Define joint clinical governance with clear roles and responsibilities

• Agree data collection criteria

• Estimate staffing requirements

• Define outcomes and performance measures

• Set up steering team (led by clinical champion) and weekly meeting

• Agree timeline for implementation, starting in September 2010.

POST ACUTE CARE ENABLEMENT

(PACE)

8

What is PACE?

• Early supportive discharge service

• Later part of an acute episode delivered in an out of hospital setting

• But still under auspices of the acute team

• On site community case finders integrate with acute team to ‘Pull’ patients

• Patient no longer requires 24hour inpatient medical care

• Patient has on-going nursing & medical monitoring needs that can be safely met outside of the hospital environment

• Content of care more medical and intensive than traditional intermediate care

• Provider to provider collaboration

An Integrated

model of care

linking with the

community

Increased

patient choice

Reduced

number of

Admissions

Reduced

Length of StayBeds closed

as a result

Delivering high

quality care

at a lower cost

Aim of PACE

• Provide an integrated model of care linking with the

community

• Increase patient choice

• Reduce number of admissions (supporting admission

avoidance team TREAT)

• Reduce length of stay

• Make bed day savings

• Deliver high quality care at a lower cost

Royal Free PACE

• Provider to provider collaboration:

– RFH

– Barnet Community Services

– Camden Provider Services

– London Boroughs of Barnet and Camden

Clinical Decision Unit

Base Wards

Urgent Care CentreAccident and Emergency

Community

Community

PACE

PA

CE

TREAT

(Triage Rapid Elderly Assessment Team)

Admission Avoidance

MAAU (72 Hour Stay)

PACE and TREAT pilots started in September 2010

Where PACE acts in the urgent care pathway

Sample case• Elderly man

• Septic

• Acute urinary retention

• Faecal impaction

• Reduced mobility

• Needs increased care package

Management plan:

PRE PACE PACE

Day 1 Catheterisation Day 1 HOME

Bowel clearance

Intravenous antibiotics

Day 2 Physiotherapy & Occupational Therapy assessment

Social services review

Day 3 Trial without catheter

Day 4 Observations for improvement

Wait for care package

Day 5 Discharge – MAY BE?

What does PACE affect?

Length of stay (LOS) in bed days

Num

ber o

f patie

nts PACE

Key:

- Optimal LOS

- Actual LOS

Conditions Suitable for PACE

• Exacerbation of COPD

• Faecal Impaction/ Urinary retention

• Simple infections- Cellulitis , UTIs

• Deep Vein Thrombosis

• Falls

• Diabetes

• All of the above + cognitive impairment

Low Acuity Patients

Typical PACE Patients Monitoring

• General observations including Postural Blood Pressure, Peak Flow, Oxygen Saturation, Blood Sugar Monitoring etc.

• Blood Tests including INR

• Administer medications including enemas & IV antibiotics

• Monitor medication & titrating analgesia

• Bowel care

• Catheter care and bladder scanning

• Wound care

• Ambulatory 24 hour ECG

• ! Assess daily & Escalate : Signs of deterioration

• ! Signposting

The clinical model

• Daily MDT board rounds (clinical champion present)

• Patients identified by medical team and on site ‘pulling’ case finders(senior experience community staff)

• Comprehensive assessment undertaken

• Clear follow-up and escalation process in place

• Patient goes home within 4 hours of acceptance onto PACE

• All onward social care needs managed by PACE team

• Up to 5 days input (flexible) and clinical responsibility remains underdischarging team

Implementation

• Must be clinically led & driven - CHAMPIONS

• Focus on few cohorts with high gains e.g. frail elderly

• Agree evaluation measures up front and make sure you capture the data

• Create the evidence base as the service develops

• PACE will surface operational issues requiring weekly meetings

• Improve by pathway mapping

• Marketing - engage and communicate with patients or clinicians (RFH and GPs)

• Educate – road shows, workshops and work alongside

Data and Outcome Measures

• Health Resource Group (HRG)

• Attendances

• Admissions

• Length of Stay (LoS)

• Re-admissions

• Patient satisfaction

• Clinical Incidents and Discharge Alerts

Evaluation of RFH PACE

• Patient satisfaction high

• Beds closed as a consequence – LOS reduction average 3 days per patient

Week 234 ( Feb 2015) Borough

Barnet Camden

Referred 4255 4654

Accepted 2995 3142

Discharged 2927 3090

Readmitted 92 153

Summary

Total Patients Referred 8909

Total Number of Patients Accepted 6137 (69%)

Total Number of Patients Discharged 6017 (98%)

Total Number of Patients Re-admitted (5 days) 245 ( 4%)

All patients with PACE

diagnosis

Length of stay now

Management Support

• Monthly PACE Operational group: – Alex Wu (chair, Clinical Director Service Transformation),

– Fran Gertler (Head of Integrated Care)

– Kam Kalirai (Associate Director of Service Improvement)

– Community MDT

• LOS and QIPP Steering group: – Katie Donlevy (Director of Service Transformation)

– Kate Slemeck (Chief Operating Officer)

– Janet Mustoe (hospital director)

– Operations and nursing managers

• Data Analysts/Administration support

• Funding

T.R.E.A.TAdmission

Avoidance

Avoid admissions through rapid multi-disciplinary assessment and treatment

7 days a week consultant led service based in A&E

Rapid access investigations and interventions.

Emergency Social packages

Work proactively with GPs, community teams and care homes

Return patients safely to the community

Specialist nurses- triage/outreach

Enhanced patient experience supported by post-discharge follow-up phone call

Prepared by Kam Kalirai Head of Service Redesign 190511

• Set up on a daily basis

• Responsive to urgent referrals

• Aim to avert crisis leading to hospital admission.

• Rapid multi-disciplinary review

• Rapid communication with primary care

• Hot lines manned by consultants

SINGLE POINT OF CONTACT

T.R.E.A.TAdmission

Avoidance

‘Hot Clinics’

‘Hot Lines’

TREAT results

• Reduced length of stay

• Patient satisfaction extremely high

• Has now attracted substantial commissioner funding

No. of patients 2011/2012 2012/2013 2013/2014

Triaged 1614 2461 2306

Suitable for TREAT

584 (30%) 863 (35%) 866 (37%)

Discharged by TREAT

477 (82%) 628 (78%) 621 (72%)

Discharged with PACE

216 (45%) 289 (48%) 268(31%)Rapid Response started

New TREAT team

• 6 consultant geriatricians

• 2 acute specialist nurses (Band 6 and 7)

• 2 community specialist nurses (Band 6)

• 2 juniors doctors F2/ST/SpR

• Occupational therapist

• Pharmacist

• Social Services

• Administrator and data analyst

• PACE/ RAPID RESPONSE TEAM

5. What did we learn?

BEFORE - The urgent care pathway

Clinical Decision Unit

Base Wards

Urgent Care CentreAccident and Emergency

Community

Community

TREAT

(Triage Rapid Elderly Assessment Team)

Admission Avoidance

MAAU (72 Hour Stay)

PACE and TREAT pilots started in September 2010

PACE

PA

CE

PACE

TREAT ADMISSIONS

LENGTH OF STAY

Increase patients’ choice of care

Lay foundation for integrated care

Increase capacity for new business

What we’ve learnt - 1

PACE

TREAT

RE-ADMISSIONS

(30 days)

ADMISSIONS

We need more than just

PACE and TREAT to drive

these down

LENGTH OF STAY

A&E ATTENDANCES

What we’ve learnt - 2

6. How did we evolve from our learning?

P

A

C

E

AFTER - New Integrated Health Care System

Extending into the Community

Community Hub

Purpose: Players:

- Case management MDT - GPs

- Multi-specialty clinics - Consultants

- Identify gaps in care - Therapists

- Social Services

- Community Matrons

- Mental Health Teams

Medical Admission

Unit (72 hours)

Attendance

PreventionFrailty screening

Target re-attenders

Care Home

Medicine

Elective

Ambulatory Care

Unit (PITU)

Day Surgery Unit

Surgical Admission

Unit (72 hours)

Base Ward (>72 hours)

Consultant-led

Assessment &

Discharge

Co-ordination Fast Diagnostics,

Clear Outcomes,

Get it right first time

E

D

U

C

A

T

I

O

N

Robust Administration, Data Collection & Quality Outcome Measures

Outreach

Domiciliary Visits

A&E Rapid Assessment Triage (RAT)

A&E (4 hours) Urgent Care Centre

Admission Avoidance (TREAT) + HOT Clinics

23 hour Emergency Assessment Unit

R

R

T

TREAT and PACE

Urgent Care Centre

A&E Re-design

Emergency Ambulatory Care Unit

RE-ADMISSIONS

(30 days)

ADMISSIONS

LENGTH OF STAY

A&E ATTENDANCES

Care Navigation Service

Community Hubs

Care Home Outreach

Elective Ambulatory Care Unit (PITU)

Day Surgery Unit

We need all the above components to achieve these targets

How we need to evolve

Next Steps for the Royal Free (1)

FRONT END REDESIGN

• new A&E /Urgent Care Centre ( £23 million)

• co-locate with a consultant led Emergency Ambulatory Care unit

• Expand across whole trust concept of ADMISSION AVOIDANCE

ASSESS TO ADMIT

HOT CLINICS

PACE / RAPID RESPONSE

• Increase productivity of ELECTIVE AMBULATORY CARE UNIT (PITU)

NEW DAY SURGERY UNIT

• Consolidate CARE NAVIGATION SERVICE

community hubs

multi-disciplinary clinics

case management

• Develop CARE HOME MEDICINE with consultant-led outreach team targeting attendance

prevention and admission avoidance

• Re-design CLINICAL PATHWAYS, incorporating community resources, PACE / RAPID

RESPONSE

Current Cellulitis Pathway

Referral routes

GP

OPD Clinics

Diabetic Foot

Plastics

Dermatology

Vascular

Scleroderma

Rheumatology

Dermatology

Heart Failure

Community Hubs

Camden and Barnet

A&E

Medical Expected ID or other speciality

Hot Clinics

ID clinics on Thursdays

Dermatology?

Vascular ?

Register patient in

Cerner

Patient assessed in

A&E

Register patient in

Cerner

Register patient in

Cerner

Patient assessed in Hot

Clinic

Patient assessed in ID

clinic

Patient treated in A&E

Patient Treated in Hot Clinic

Patient Treated in ID clinic

Does pt needs

Admission

Request a bed

OPATS 11 West day case ID Thursday

Pt given oral antibiotics and

home

PACE Ambulatory

A&EAmbulatory

first dose given in A&E

first dose IV given in A&E

Discharged to PACE

Patient attends Daily for 2ND & 3rd

dose given in GQ clinical review

Has patient

responds to iv

Pt given oral antibiotics and

home

Patient referred to ID 15% admitted

NO

NO

YES

YES

Patient assessed in

A&E by medical team

Patient treated in A&E

Currently there are several pathways for different specialties treating patients with cellulitis which has resulted in ; A range of different protocols

15% of patients with cellulitis in seen in A&E are admitted and 85% of patients are discharged home or are on an ambulatory pathway

When admitted, patients have a mean hospital stay of 5 days (patients aged 65 years or over stay 7 days on average)

40% of the patients with a significant clinical comorbidity These account for 62% of the cellulitis bed days demonstrating that long

length of stay is associated with factors other than the cellulitis diagnosis and is affected by other underlying conditions.

Streamlined Cellulitis Pathway

PACE (Short duration IVs up to Seven days for immobile patients)OPATS in PITU for patients with long lines and longer than 14 days antibiotics

GP

Community HubsCamden and

Barnet

A&E/Urgent Care assessed and treated as pre

agreed ALGORITHM

Stevenson House

Finchley Memorial

A simple AlgorithmPatient checked in and triaged in A&E(TELE- MEDINICE)

Ambulatory 23 HR Hot Clinics for IVs and

medical review for ambulatory pt

23 hour unit leads admission

Discharge home oral antibiotics

Patient discharged home

OPD Appointment in PITU/OPATS for

patients with long lines

Finchley Memorial community infusion

hub for review and IV

Patient discharged home,

+ /-PACE +/- PITU OPATS

PACE for non-ambulatory patient

and needs IV antibiotics for up to 7 days but not admission

Does pt needs

Admission

NO

Patient admitted to MAU

Patient admitted to a Base Ward

YES

The A&E/23hr clinical redesign team have designed an integrated cellulitis pathway supported by a simple treatment algorithm to reduce variation in clinical practice.

Next Steps for the Royal Free (2)

•Extend the PACE &TREAT model for other specialities & our newly merged Trust

• PACE delirium/dementia

• PACE surgical (colorectal and vascular)

• PACE specialist services (infectious diseases)

• PACE rehabilitation

• PACE renal medicine

• Use of voluntary services to follow up PACE discharge

• Build an integrated IT system to provide real-time patient information

• Robust training programme established focusing on practical skills & acute

medical problems

• Create joint primary (GPs) & secondary care appointments

• Marketing - conduct regular workshops & GP forums to create awareness

• Evaluation, research & consultancy

• 7-DAY WORKING

oDrop in to meet & talk to specialist nurses

oAsk questions about policies & practices

oFind out more about competencies

oSupport your PREP requirements

Many specialist nursing teams will be available on the day:Infection control Stoma nurses Medical electronicsNursing directorate Dementia nurse consultant Palliative careUrology nurses Continence nurses Diabetes nursesBlood transfusion & many, many more....

oPractice your clinical skills

oCheck your knowledge & skills

oSeek advice and support

oPick up some literature

More information to follow...

7. Summary & Conclusions

Integrated Care - Summary & Conclusions

Clinical Champions &

Strong OperationalManagement

& Governance

Communications &

Marketing

EliminateService

silos

Education &

Training

Years

Good patient outcome

Enhanced patient

experience

Avoidance of

inappropriate or

unnecessary hospital

based activities

Value for money

Value

Making integrated health care system works take years not months. The true

value of the new Integrated Health Care System is about developing

partnerships and new ways of working, delivering good patient outcome

and value for money in the long term.

Integrated IT

System

Data Analysis

& Research

This takes years and

subject to evolution!

A champion is essential

LEARNING POINTS

• Champions – Grow your own and clone them !

• Marketing

• Educate – Work alongside

• Learn from the best

• Spot the gaps and evolve

• Tough on data / clear on process

• Ask daily – What can be done better? And it

can be done!

• Don’t give up too soon

Thank You

Questions?