Integrated Care Management

Population Management Model

Supported Self Care

Care

Management

Health Promotion

Population wide prevention

Care coordination

Most Complex

Range of risk

Education

Education Lifestyle

What is Integrated Care Management ?

Proactive approach High risk patientsMedical/nursing/pharmaceutical/social

needs Undertaken by Qualified

ProfessionalSuitable trained and competent

What does it involve? Full assessment medical, nursing,

pharmaceutical and social care needs Develop personalised holistic care plans Involve patients and carers as partners Highly visible Lead role Secure services/ treatments modalities Teach pt/ carers monitor condition Maintain contact through hospital

admissions Cross boundary working

Potential Benefits

Better outcomes for individuals, their families, carers and communities

Improved access to services Reduction in the use of unplanned care Improved concordance with medication Improved partnership working Reduction in the number of professionals involved in

the individuals care Improved choice Greater continuity of support / care / involvement More control in the package of care / support

provided Improved and speedier decision making Empowerment of individual through active

participation in the process

Care Managers Training(Health Staff)

Advanced clinical assessment skills

Physical examination skills Minor Major Illness Injury

Nurse Treatment Service (MINTS)

Independent and Supplementary prescribing

Care Management Training

Lanarkshire Pilots 12 month pilots Outcome Measures

Admission rates, LOS, pharmaceutical care, GP attendances, clinical consultations, equipment, social care service utilisation, patient, carer, staff satisfaction

Most effective approaches rolled out across Lanarkshire

Lanarkshire Locality pilots

High Risk by Gender

High Risk : Total Bed Days used

High Risk group and number of Emergency Admissions

Emergency Admissions Vs Total Bed Days

Principal Diagnosis of High Risk

High Risk cohort by Probability

Probability Vs Diagnosis

SPARRA Outcomes in Lanarkshire

Coatbridge Clydesdale East Kilbride Total

Total High Risk 81 42 44 167

Deceased 26 14 8 48

Improvement in Health (Data Review) 28 0 18 46

residing in Long Term Care 7 3 9 19

Outwith Catchment areas 7 1 3 11

Palliative Care 1 0 0 1

Patient refused Assessment 0 4 0 4

Offered Full assessment 11 18 3 32

Accepted 8 10 2 20

Refused 3 8 1 12

Refusal Reason- Client refused 1 0 0 1 Improvement in Health 2 5 0 7 Unknown 0 3 0 3 Undergoing Assess LTC 0 0 1 1

SPARRA Outcomes

29%

29%

12%

7%

1%

2%

20%

Deceased

Improvement in Health(Data Review)

Residing in Long TermCare

Outwith Catchmentareas

Palliative Care

Patient refusedAssessment

Offered Fullassessment

38%

Offerred Full Assessments

62% (20)

38% (12)

Accepted

Refused

Refusal Reasons

1

7

3

1

0

1

2

3

4

5

6

7

8

Clientrefused

Improvementin Health

Unknown UndergoingAssess LTC

Shared Learning