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  • 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


    Results in length of stay reductions and admissions


  • 3. Whats 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 patients 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.




  • 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



    patient choice


    number of



    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


    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:


    Barnet Community Services

    Camden Provider Services

    London Boroughs of Barnet and Camden

  • Clinical Decision Unit

    Base Wards

    Urgent Care CentreAccident and Emergency







    (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


    Acute urinary retention

    Faecal impaction

    Reduced mobility

    Needs increased care package

    Management plan:


    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


    ber o

    f patie

    nts PACE


    - Optimal LOS

    - Actual LOS

  • Conditions Suitable for PACE

    Exacerbation of COPD

    Faecal Impaction/ Urinary retention

    Simple infections- Cellulitis , UTIs

    Deep Vein Thrombosis



    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)



    Length of Stay (LoS)


    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


    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


  • 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


  • T.R.E.A.TAdmission


    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





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