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Starting high, aiming higher
We have achieved substantial improvements for our community and receive positive feedback from patients and the public
Both the Care Trust and Foundation Trust were finalists in the HSJ PCT/Acute Trust of the year in 2009
But we know we can and must do better
The community journey
1991 Whole district trust
1992-7 GP fund-holding
2000 Integrated Care Network plan
2005 Torbay Care Trust
2009 Integrated Care Organisation pilot
Key lessons and hard choices
Partnerships
Innovation
Managing the system Nurses and workforce Diagnostics and decision support 24/7 versus local Facilities, equipment and co-ordination
What has Mrs Smith experienced?
1991 Working in Brixham
1995 Her mother needs a hip replacement, spends 2 weeks in Exeter having waited 12 months for surgery. Has a stroke 1 month later and spends 30 days in Torbay and 60 days at Paignton before discharge to a nursing home for 6 months. Dies.
2000 Retires. Husband has MI, waits for 3 weeks in hospital before transferring to London for surgery.
2008 Husband develops heart failure and dies 18 months later following 4 admissions
What would happen today? Mother has hip replacement 3 months after
seeing her GP. Date arranged to enable holiday with daughter pre-op. Enhanced recovery and VTE prophylaxis mean mum home 3 days post-op without complications.
Husband has chest pain. Calls 999 and has angioplasty 74 minutes later. Changes lifestyle.
Couple living happily and enjoying grandchildren.
The new challenge
2009 2019 Change
Population 140000 160000 +20000
Estimated non-elective admissions
37000 44000 +7000
Cash for non-elective admissions
£67m £67m +0
Cash per case
£1825 £1525 -£300
No change!Add £13m
£82 eachSay £500 per familyAnd this in only 25% of the health budget
Needs are changing
Condition No.
Condition Name New CodingNew Weight
Old Weight
1Acute myocardial infarction
I21, I22, I23, I252, I258 5 1
2Cerebral vascular accident
G450, G451, G452, G454, G458, G459, G46, I60-I69
11 1
3Congestive heart failure
I50 13 1
4Connective tissue disorder
M05, M060, M063, M069, M32, M332, M34, M353
4 1
5 Dementia F00, F01, F02, F03, F051 14 1
6 Diabetes
E101, E105, E106, E108, E109, E111, E115, E116, E118, E119, E131, E131, E136, E138, E139, E141, E145, E146, E148, E149
3 1
7 Liver disease K702, K703, K717, K73, K74 8 18 Peptic ulcer K25, K26, K27, K28 9 1
9Peripheral vascular disease
I71, I739, I790, R02, Z958, Z959 6 1
10Pulmonary disease
J40-J47, J60-J67 4 1
11 Cancer C00-C76, C80-C97 8 2
12Diabetes complications
E102, E103, E104, E107, E112, E113, E114, E117, E132, E133, E134, E137, E142, E143, E144, E147
-1 2
13 Paraplegia G041, G81, G820, G821, G822 1 2
14 Renal diseaseI12, I13, N01, N03, N052-N056, N072-N074, N18, N19, N25
10 2
15 Metastatic cancer C77, C78, C79 14 3
16Severe liver disease
K721, K729, K766, K767 18 3
17 HIV B20, B21, B22, B23, B24 2 6
10-19
20-49
Integration is part of the solution
Excite, delight, simplify
Preventative
Actions taken to avoid onset of known conditions
Immediate Intervention
Services in community which prevent admission to acute
Acute
Safe and efficient management of condition during acute intervention
Reablement
Services provided to maximise independence following acute admission or crisis
Palliative
Providing high quality care during end of life and enabling patients to die in place of choice
Virtual Pooled Budget for Older Peoples’ Care
Assistive Technolo
gy to support COPD
patients
Emergency Care
Practitioners
supporting falls
RACE Clinics
Primary &
secondary care
Medical Model
Emergency
Admission to
Hospital for
complex conditionsHospital Discharg
eCo-
ordinators
Community
Hospitals Medical
Evaluation
Orthopaedic Pathway
COPD/CCF/
Dementia in
Nursing Homes
End of life care Training
Pro-active care for Mr and Mrs Smith
Self care when possible Tele-health support for high risk
periods Packages of care optimised to
maximise benefits Pro-active intervention when
markers indicate increasing risk
And for the care team
Investments to optimise capacity of local care settings and teams
Efficient support to optimise decision making and promote flexibility
Real time feedback of results and alerts accelerates improvement in outcomes
Virtual activity Specialists support frontline teams
What does this means for Mrs Smith?
2020Getting more frail and forgetful. Husband has diabetes and some heart failure. Daughters live in London and Scotland
Local support network in place (based in local nursing facility) to respond to issues detected by home monitoring system. Mr Smith has not needed to visit practice or hospital due to real-time monitoring and medication management system.
Daughters can support care through video link and access to shared records