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
Q2 BCBV sets baseline
The community journey Whole district trust 1992-7 GP fund-holding 2000 Integrated Care Network plan 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 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. Retires. Husband has MI, waits for 3 weeks in hospital before transferring to London for surgery. 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 No change! Add £13m £82 each Say £500 per family And this in only 25% of the health budget
Needs are changing 10-19 20-49
What should we be dreaming about today to meet this challenge ?
Imagineering b. 1928, lives forever
Integration is part of the solution Excite, delight, simplify
Experience is growing
Virtual Pooled Budget for Older Peoples’ Care Assistive Technology to support COPD patients RACE Clinics Emergency Admission to Hospital for complex conditions Community Hospitals Medical Evaluation COPD/CCF/Dementia in Nursing Homes Emergency Care Practitioners supporting falls Primary & secondary care Medical Model Hospital Discharge Co-ordinators Orthopaedic Pathway 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? Getting 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