The work of SLIC 29th April 2014

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Southwark and Lambeth covers a population of 600,000 people; we have world-class medical institutions but worse than average health outcomes and deprivation

St Thomas’s Hospital

King’s College Hospital SLaM

Guy’s Hospital

Source: Health Profiles 2013

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Providers of care

Leaders and citizens across the care system have come together to improve value: raising quality and experience whilst reducing overall costs

Commissioners of care Academic partners

Local CCGs and LAs LAs, GPs and FTs AHSC

Southwark and Lambeth Integrated Care

Champions of change

Citizens’ Board &

Citizens’ Forum

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Our initial focus has been with the frail and elderly: The Older People’s Programme focuses on resolving real challenges for the system…

• Falls• Infection• Nutrition• Dementia

L2

L1

L3 How can I look after myself?Who gives me the advice I need?

Is anyone looking out for my condition getting worse?

Proactive management: the most complex patients often lack targeted interventions to manage their health

b

??

Internal and external processes often make it difficult to discharge people in a timely and

effective way

GP

Clinical pathways: there is too little focus on preventing ill health in the general

population

a

Too little emphasis is placed on keeping people healthy and avoiding the development of crises

A&E

Early identification and intervention to avoid crisis3

Providing alternative urgent response1 Reducing delays to discharge to maximise independent living2

There are too few options other than the hospital, so people who don’t need

it end up in acute care

Anticipated benefits

By 2015/16:

Bed Reduction(through reduced admissions & LOS)

• 23,500 bed days saved• Equates to 32 beds for each acute

Social Care Reduction• 20% reduction in residential packages• Equates to 133 less packages of care

Improved patient experience

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…it aims to deal with the source of the demand rather than just to deal with the consequences of ever-increasing activity

?

Turn off the tap Mop up the water

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A range of different interventions are being tested to see if they help address our core challenges

Target Population

• TALK helpline• Hot clinic• Enhanced rapid response• @Home

Providing alternative urgent response

• Simplified discharge• Reablement

Reducing delays to discharge to maximise

independent living

• Risk stratification, proactive assessments, care management and CMDTs

• Care homes & home care

Proactive identification &

intervention

• Falls• Infections• Nutrition • Dementia

Improved clinical pathwaysEa

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1

2

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SLIC Aim SLIC Intervention

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Through the course of the programme we have begun to see a change in practice, which is demonstrated through a change in activity…

3837 people have had a Holistic Health Assessment within General Practice to generate their care plan

1749 people have had their care supported with enhanced nursing, therapy and social care support in community so they do not

need to be in hospital

General Practice & Community staff have

gained immediate advice from a

Consultant in Geriatric Medicine 345 times

205 people have seen a consultant in Geriatric Medicine following an urgent

referral from General Practice

1158 people have had their care discussed at

a Community Multi-disciplinary Team

Meeting

410 people have had their care co-ordinated by an Integrated Care

Manager

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…and more importantly, through an improvement in the care experiences of real people like Norman

Norman is 82 years old and lives alone in a warden controlled flat.

He attends A&E regularly but never requires admission.

He was referred to and discussed at a CMDT

The Integrated Care Manager (ICM) looked into the pattern of Norman’s A&E attendances; they were always on Sunday afternoons.

The ICM spoke with Norman and found out that Norman has meals on wheels Mon-Fri lunchtimes.

He has no other cooking facilities in his home, so in the evenings and on a Saturday, Norman goes to his local cafe.

The cafe is not open on Sundays. Norman told the ICM that he goes to A&E on a Sunday as he likes the lunch they give him and the company.

The ICM arranged for Norman to have meals on wheels changed so that he received lunch and dinner on a Sunday and the ICM has arranged for a tea gathering to happen on Sunday afternoons in his block of flats to help with his loneliness.

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However stories of our citizens indicate we need to transform the care system…

Bob Jane

Bob had a stroke in 2009 which left with anextremely limited ability to speak.

He was taken to A&E by his carers several times and admitted due to pain

The geriatrician noticed that Bob had been in hospital several times and referred him to a CMDT.

To understand the cause of his pain, the CMDT arranged for speech and language therapists to work with Bob.

They found out that he had the ability to communicate through pictures. The CMDT identified that Bob had a frequent turnover of carers and they were finding it very difficult to communicate with him.

All those who work with Bob now use pictures. This has resulted in Bob being able to communicate, he is in less pain, he is less stressed and there is a significant reduction in his attendances at A&E.

Jane lives on an estate in Southwark.

She has poor balance, so she uses crutches to help her walk

She volunteers in her local estate office to help with her wellbeing

She is nervous on her crutches and has falls occasionally

She needs a wheelchair in winter as she feels unsafe on crutches

She does not meet the criteria for a wheelchair

Over winter for 5 months she stays indoors, her depression worsens and she gets admitted to a local Mental Health Trust