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<ul><li><p>Royal Free London </p><p>NHS Foundation Trust</p><p>Our Integrated Care Journey</p><p>Dr. Alexandra Wu</p><p>Clinical Director </p><p>Service Transformation</p></li><li><p>The Royal Free</p><p>Integrated Care Journey</p><p>Scope and Contents</p><p> What is integrated care?</p><p> Why do integrated care?</p><p> What is involved?</p><p> How did we do it?</p><p> What did we learn?</p><p> How did we evolve from our learning?</p><p> Summary and conclusions</p><p> Questions &amp; Answers</p></li><li><p>The Royal Free Licensed as a Foundation </p><p>Trust since April 2012</p><p> Merged with Barnet and </p><p>Chase Farm Hospitals </p><p>(July 2014)</p><p> 1 Billion turnover</p><p> 10,000 full-time staff</p><p> 1100 beds approximately</p><p> Teaching hospital and a </p><p>tertiary with district </p><p>general function</p></li><li><p>1. What is integrated care?</p><p> Meeting the needs of individuals by flexible and </p><p>seamless working across multiple organisations to </p><p>deliver optimal and personalised care whether in </p><p>hospital or at home</p><p> This is a collective responsibility between the </p><p>primary and secondary sectors.</p></li><li><p>2. Why do integrated care?</p><p> Current economic environment for the NHS</p><p> QIPP - Imperative is to achieve best in class </p><p>clinical productivity (length of stay, re-admissions, </p><p>excess bed days) </p><p> Clinically led pathway redesign focused on patient </p><p>cohorts</p><p> Results in length of stay reductions and admissions </p><p>avoidance</p></li><li><p>3. Whats involved Two innovations in September 2010</p><p> Post Acute Care Enablement (PACE)</p><p> Triage Rapid Elderly Assessment Team (TREAT)</p><p> Patient cohort</p><p> Complex, elderly patients</p><p> Urgent care division </p><p> Department involved</p><p> Health Services for Elderly People (HSEP)</p><p> 3,200 emergency admissions/year, 40% of acute take</p><p> Chronic long-term conditions, care homes, variable acuity</p><p> Aim to deliver a different model of care</p><p> Reduce admissions</p><p> Early support discharge </p><p> As safe and as high quality but in a lower cost setting</p><p> Funding and resources</p><p> Closure of 18 bedded acute medical ward to re-direct funding for the innovations</p><p> Appointed Dr. Alexandra Wu as clinical champion and Kam Karilai as project </p><p>manager under the direction of Katie Donlevy, Director of Integrated Care</p></li><li><p>4. How did we do it? Brainstorm with multi agencies in May 2010</p><p> Build relationships, establish capabilities and facilities available </p><p> Identify patient groups and wards</p><p> Map out patients pathway, define process and logistics</p><p> Define joint clinical governance with clear roles and responsibilities</p><p> Agree data collection criteria</p><p> Estimate staffing requirements</p><p> Define outcomes and performance measures</p><p> Set up steering team (led by clinical champion) and weekly meeting</p><p> Agree timeline for implementation, starting in September 2010.</p></li><li><p>POST ACUTE CARE ENABLEMENT </p><p>(PACE)</p><p>8</p></li><li><p>What is PACE?</p><p> Early supportive discharge service</p><p> Later part of an acute episode delivered in an out of hospital setting</p><p> But still under auspices of the acute team</p><p> On site community case finders integrate with acute team to Pull patients</p><p> Patient no longer requires 24hour inpatient medical care</p><p> Patient has on-going nursing &amp; medical monitoring needs that can be safely met outside of the hospital environment</p><p> Content of care more medical and intensive than traditional intermediate care</p><p> Provider to provider collaboration</p><p>An Integrated</p><p>model of care</p><p>linking with the</p><p>community</p><p>Increased </p><p>patient choice</p><p>Reduced </p><p>number of </p><p>Admissions</p><p>Reduced </p><p>Length of StayBeds closed </p><p>as a result</p><p>Delivering high</p><p>quality care </p><p>at a lower cost</p></li><li><p>Aim of PACE</p><p> Provide an integrated model of care linking with the </p><p>community</p><p> Increase patient choice</p><p> Reduce number of admissions (supporting admission </p><p>avoidance team TREAT)</p><p> Reduce length of stay</p><p> Make bed day savings</p><p> Deliver high quality care at a lower cost</p></li><li><p>Royal Free PACE</p><p> Provider to provider collaboration:</p><p> RFH</p><p> Barnet Community Services</p><p> Camden Provider Services</p><p> London Boroughs of Barnet and Camden</p></li><li><p>Clinical Decision Unit</p><p>Base Wards</p><p>Urgent Care CentreAccident and Emergency</p><p>Community</p><p>Community</p><p>PACE</p><p>PA</p><p>CE</p><p>TREAT</p><p>(Triage Rapid Elderly Assessment Team)</p><p>Admission Avoidance</p><p>MAAU (72 Hour Stay)</p><p>PACE and TREAT pilots started in September 2010</p><p>Where PACE acts in the urgent care pathway</p></li><li><p>Sample case Elderly man</p><p> Septic</p><p> Acute urinary retention</p><p> Faecal impaction</p><p> Reduced mobility</p><p> Needs increased care package</p><p>Management plan: </p><p>PRE PACE PACE </p><p>Day 1 Catheterisation Day 1 HOME</p><p>Bowel clearance </p><p>Intravenous antibiotics</p><p>Day 2 Physiotherapy &amp; Occupational Therapy assessment</p><p>Social services review</p><p>Day 3 Trial without catheter</p><p>Day 4 Observations for improvement</p><p>Wait for care package</p><p>Day 5 Discharge MAY BE?</p></li><li><p>What does PACE affect?</p><p>Length of stay (LOS) in bed days</p><p>Num</p><p>ber o</p><p>f patie</p><p>nts PACE</p><p>Key:</p><p>- Optimal LOS</p><p>- Actual LOS</p></li><li><p>Conditions Suitable for PACE</p><p> Exacerbation of COPD</p><p> Faecal Impaction/ Urinary retention</p><p> Simple infections- Cellulitis , UTIs </p><p> Deep Vein Thrombosis</p><p> Falls</p><p> Diabetes</p><p> All of the above + cognitive impairment</p><p>Low Acuity Patients</p></li><li><p>Typical PACE Patients Monitoring</p><p> General observations including Postural Blood Pressure, Peak Flow, Oxygen Saturation, Blood Sugar Monitoring etc.</p><p> Blood Tests including INR</p><p> Administer medications including enemas &amp; IV antibiotics</p><p> Monitor medication &amp; titrating analgesia</p><p> Bowel care</p><p> Catheter care and bladder scanning</p><p> Wound care</p><p> Ambulatory 24 hour ECG </p><p> ! Assess daily &amp; Escalate : Signs of deterioration</p><p> ! Signposting</p></li><li><p>The clinical model</p><p> Daily MDT board rounds (clinical champion present)</p><p> Patients identified by medical team and on site pulling case finders(senior experience community staff)</p><p> Comprehensive assessment undertaken</p><p> Clear follow-up and escalation process in place</p><p> Patient goes home within 4 hours of acceptance onto PACE</p><p> All onward social care needs managed by PACE team</p><p> Up to 5 days input (flexible) and clinical responsibility remains underdischarging team</p></li><li><p>Implementation</p><p> Must be clinically led &amp; driven - CHAMPIONS</p><p> Focus on few cohorts with high gains e.g. frail elderly</p><p> Agree evaluation measures up front and make sure you capture the data</p><p> Create the evidence base as the service develops</p><p> PACE will surface operational issues requiring weekly meetings</p><p> Improve by pathway mapping</p><p> Marketing - engage and communicate with patients or clinicians (RFH and GPs)</p><p> Educate road shows, workshops and work alongside</p></li><li><p>Data and Outcome Measures</p><p> Health Resource Group (HRG) </p><p> Attendances</p><p> Admissions</p><p> Length of Stay (LoS)</p><p> Re-admissions</p><p> Patient satisfaction</p><p> Clinical Incidents and Discharge Alerts</p></li><li><p>Evaluation of RFH PACE</p><p> Patient satisfaction high</p><p> Beds closed as a consequence LOS reduction average 3 days per patient</p><p>Week 234 ( Feb 2015) Borough</p><p>Barnet Camden</p><p>Referred 4255 4654</p><p>Accepted 2995 3142</p><p>Discharged 2927 3090</p><p>Readmitted 92 153</p><p>Summary</p><p>Total Patients Referred 8909</p><p>Total Number of Patients Accepted 6137 (69%)</p><p>Total Number of Patients Discharged 6017 (98%)</p><p>Total Number of Patients Re-admitted (5 days) 245 ( 4%)</p></li><li><p>All patients with PACE </p><p>diagnosis</p></li><li><p>Length of stay now</p></li><li><p>Management Support</p><p> Monthly PACE Operational group: Alex Wu (chair, Clinical Director Service Transformation), </p><p> Fran Gertler (Head of Integrated Care) </p><p> Kam Kalirai (Associate Director of Service Improvement) </p><p> Community MDT</p><p> LOS and QIPP Steering group: Katie Donlevy (Director of Service Transformation)</p><p> Kate Slemeck (Chief Operating Officer) </p><p> Janet Mustoe (hospital director) </p><p> Operations and nursing managers</p><p> Data Analysts/Administration support</p><p> Funding</p></li><li><p>T.R.E.A.TAdmission</p><p>Avoidance</p><p> Avoid admissions through rapid multi-disciplinary assessment and treatment</p><p> 7 days a week consultant led service based in A&amp;E</p><p> Rapid access investigations and interventions.</p><p> Emergency Social packages</p><p> Work proactively with GPs, community teams and care homes</p><p> Return patients safely to the community</p><p> Specialist nurses- triage/outreach</p><p> Enhanced patient experience supported by post-discharge follow-up phone call</p></li><li><p>Prepared by Kam Kalirai Head of Service Redesign 190511</p><p> Set up on a daily basis</p><p> Responsive to urgent referrals</p><p> Aim to avert crisis leading to hospital admission.</p><p> Rapid multi-disciplinary review</p><p> Rapid communication with primary care</p><p> Hot lines manned by consultants</p><p>SINGLE POINT OF CONTACT</p><p>T.R.E.A.TAdmission</p><p>Avoidance</p><p>Hot Clinics</p><p>Hot Lines</p></li><li><p>TREAT results </p><p> Reduced length of stay</p><p> Patient satisfaction extremely high</p><p> Has now attracted substantial commissioner funding</p><p>No. of patients 2011/2012 2012/2013 2013/2014</p><p>Triaged 1614 2461 2306</p><p>Suitable for TREAT</p><p>584 (30%) 863 (35%) 866 (37%)</p><p>Discharged by TREAT</p><p>477 (82%) 628 (78%) 621 (72%)</p><p>Discharged with PACE</p><p>216 (45%) 289 (48%) 268(31%)Rapid Response started</p></li><li><p>New TREAT team</p><p> 6 consultant geriatricians</p><p> 2 acute specialist nurses (Band 6 and 7)</p><p> 2 community specialist nurses (Band 6)</p><p> 2 juniors doctors F2/ST/SpR</p><p> Occupational therapist</p><p> Pharmacist</p><p> Social Services</p><p> Administrator and data analyst</p><p> PACE/ RAPID RESPONSE TEAM</p></li><li><p>5. What did we learn? </p></li><li><p>BEFORE - The urgent care pathway</p><p>Clinical Decision Unit</p><p>Base Wards</p><p>Urgent Care CentreAccident and Emergency</p><p>Community</p><p>Community</p><p>TREAT</p><p>(Triage Rapid Elderly Assessment Team)</p><p>Admission Avoidance</p><p>MAAU (72 Hour Stay)</p><p>PACE and TREAT pilots started in September 2010</p><p>PACE</p><p>PA</p><p>CE</p></li><li><p>PACE</p><p>TREAT ADMISSIONS</p><p>LENGTH OF STAY</p><p>Increase patients choice of care</p><p>Lay foundation for integrated care</p><p>Increase capacity for new business</p><p>What weve learnt - 1</p></li><li><p>PACE</p><p>TREAT</p><p>RE-ADMISSIONS </p><p>(30 days)</p><p>ADMISSIONS</p><p>We need more than just </p><p>PACE and TREAT to drive </p><p>these down</p><p>LENGTH OF STAY</p><p>A&amp;E ATTENDANCES</p><p>What weve learnt - 2</p></li><li><p>6. How did we evolve from our learning?</p></li><li><p>P</p><p>A</p><p>C</p><p>E</p><p>AFTER - New Integrated Health Care System</p><p>Extending into the Community</p><p>Community Hub</p><p>Purpose: Players:</p><p>- Case management MDT - GPs</p><p>- Multi-specialty clinics - Consultants</p><p>- Identify gaps in care - Therapists</p><p>- Social Services</p><p>- Community Matrons</p><p>- Mental Health Teams</p><p>Medical Admission </p><p>Unit (72 hours)</p><p>Attendance</p><p>PreventionFrailty screening</p><p>Target re-attenders</p><p>Care Home</p><p>Medicine</p><p>Elective </p><p>Ambulatory Care </p><p>Unit (PITU)</p><p>Day Surgery Unit</p><p>Surgical Admission </p><p>Unit (72 hours)</p><p>Base Ward (&gt;72 hours)</p><p>Consultant-led</p><p>Assessment &amp; </p><p>Discharge </p><p>Co-ordination Fast Diagnostics, </p><p>Clear Outcomes,</p><p>Get it right first time</p><p>E</p><p>D</p><p>U</p><p>C</p><p>A</p><p>T</p><p>I</p><p>O</p><p>N</p><p>Robust Administration, Data Collection &amp; Quality Outcome Measures</p><p>Outreach </p><p>Domiciliary Visits</p><p>A&amp;E Rapid Assessment Triage (RAT)</p><p>A&amp;E (4 hours) Urgent Care Centre</p><p>Admission Avoidance (TREAT) + HOT Clinics</p><p>23 hour Emergency Assessment Unit</p><p>R</p><p>R</p><p>T</p></li><li><p>TREAT and PACE</p><p>Urgent Care Centre</p><p>A&amp;E Re-design</p><p>Emergency Ambulatory Care Unit</p><p>RE-ADMISSIONS </p><p>(30 days)</p><p>ADMISSIONS</p><p>LENGTH OF STAY</p><p>A&amp;E ATTENDANCES</p><p>Care Navigation Service </p><p>Community Hubs</p><p>Care Home Outreach</p><p>Elective Ambulatory Care Unit (PITU)</p><p>Day Surgery Unit</p><p>We need all the above components to achieve these targets</p><p>How we need to evolve</p></li><li><p>Next Steps for the Royal Free (1)</p><p>FRONT END REDESIGN </p><p> new A&amp;E /Urgent Care Centre ( 23 million)</p><p> co-locate with a consultant led Emergency Ambulatory Care unit </p><p> Expand across whole trust concept of ADMISSION AVOIDANCE</p><p>ASSESS TO ADMIT</p><p>HOT CLINICS </p><p>PACE / RAPID RESPONSE</p><p> Increase productivity of ELECTIVE AMBULATORY CARE UNIT (PITU)</p><p>NEW DAY SURGERY UNIT</p><p> Consolidate CARE NAVIGATION SERVICE </p><p>community hubs</p><p>multi-disciplinary clinics </p><p>case management</p><p> Develop CARE HOME MEDICINE with consultant-led outreach team targeting attendance </p><p>prevention and admission avoidance</p><p> Re-design CLINICAL PATHWAYS, incorporating community resources, PACE / RAPID </p><p>RESPONSE</p></li><li><p>Current Cellulitis Pathway</p><p>Referral routes</p><p>GP</p><p>OPD Clinics</p><p>Diabetic Foot</p><p>Plastics</p><p>Dermatology</p><p>Vascular</p><p>Scleroderma</p><p>Rheumatology</p><p>Dermatology</p><p>Heart Failure</p><p>Community Hubs</p><p>Camden and Barnet</p><p>A&amp;E</p><p>Medical Expected ID or other speciality</p><p>Hot Clinics</p><p>ID clinics on Thursdays</p><p>Dermatology?</p><p>Vascular ?</p><p>Register patient in </p><p>Cerner</p><p>Patient assessed in </p><p>A&amp;E</p><p>Register patient in </p><p>Cerner</p><p>Register patient in </p><p>Cerner</p><p>Patient assessed in Hot </p><p>Clinic</p><p>Patient assessed in ID </p><p>clinic</p><p>Patient treated in A&amp;E</p><p>Patient Treated in Hot Clinic</p><p>Patient Treated in ID clinic</p><p>Does pt needs </p><p>Admission</p><p>Request a bed</p><p>OPATS 11 West day case ID Thursday</p><p>Pt given oral antibiotics and </p><p>home</p><p>PACE Ambulatory</p><p>A&amp;EAmbulatory</p><p>first dose given in A&amp;E</p><p>first dose IV given in A&amp;E</p><p>Discharged to PACE</p><p>Patient attends Daily for 2ND &amp; 3rd</p><p>dose given in GQ clinical review</p><p>Has patient </p><p>responds to iv </p><p>Pt given oral antibiotics and </p><p>home</p><p>Patient referred to ID 15% admitted</p><p>NO</p><p>NO</p><p>YES</p><p>YES</p><p>Patient assessed in </p><p>A&amp;E by medical team</p><p>Patient treated in A&amp;E</p><p> Currently there are several pathways for different specialties treating patients with cellulitis which has resulted in ; A range of different protocols</p><p> 15% of patients with cellulitis in seen in A&amp;E are admitted and 85% of patients are discharged home or are on an ambulatory pathway</p><p> When admitted, patients have a mean hospital stay of 5 days (patients aged 65 years or over stay 7 days on average)</p><p> 40% of the patients with a significant clinical comorbidity These account for 62% of the cellulitis bed days demonstrating that long </p><p>length of stay is associated with factors other than the cellulitis diagnosis and is affected by other underlying conditions.</p></li><li><p>Streamlined Cellulitis Pathway</p><p>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</p><p>GP</p><p>Community HubsCamden and </p><p>Barnet</p><p>A&amp;E/Urgent Care assessed and treated as pre </p><p>agreed ALGORITHM</p><p>Stevenson House</p><p>Finchley Memorial </p><p>A simple AlgorithmPatient checked in and triaged in A&amp;E(TELE- MEDINICE)</p><p>Ambulatory 23 HR Hot Clinics for IVs and</p><p>medical review for ambulatory pt </p><p>23 hour unit leads admission </p><p>Discharge home oral antibiotics</p><p>Patient discharged home</p><p>OPD Appointment in PITU/OPATS for </p><p>patients with long lines </p><p>Finchley Memorial community infusion </p><p>hub for review and IV</p><p>Patient discharged home, </p><p>+ /-PACE +/- PITU OPATS</p><p>PACE for non-ambulatory patient </p><p>and needs IV antibiotics for up to 7 days but not admission</p><p>Does pt needs </p><p>Admission</p><p>NO</p><p>Patient admitted to MAU</p><p>Patient admitted to a Base Ward</p><p>YES</p><p>The A&amp;E/23hr clinical redesign team have designed an integrated cellulitis pathway supported by a simple treatment algorithm to reduce variation in clinical practice.</p></li><li><p>Next Steps for the Royal Free (2)</p><p>Extend the PACE &amp;TREAT model for other specialities &amp; our newly merged Trust</p><p> PACE delirium/dementia</p><p> PACE surgical (colorectal and vascular)</p><p> PACE specialist services (infectious diseases) </p><p> PACE rehabilitation</p><p> PACE renal medicine</p><p> Use of voluntary services to follow up PACE discharge</p><p> Build an integrated IT system to provide real-time patient information</p><p> Robust training programme established focusing on practical skills &amp; acute </p><p>medical problems</p><p> Create joint primary (GPs) &amp; secondary care appointments</p><p> Marketing - conduct regular workshops &amp; GP forums to create awareness</p><p> Evaluation, research &amp; consultancy </p><p> 7-DAY WORKING</p></li><li><p>oDrop in to meet &amp; talk to specialist nurses</p><p>oAsk questions about policies &amp; practices</p><p>oFind out more about competenc...</p></li></ul>

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