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  • 1. Integrated Care – Where next?
    Sasha Karakusevic
  • 2. 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
  • 3. Q2 BCBV sets baseline
  • 4. The community journey
    Whole district trust
    1992-7 GP fund-holding
    2000 Integrated Care Network plan
    Torbay Care Trust
    2009 Integrated Care Organisation pilot
  • 5. Key lessons and hard choices
    Managing the system
    Nurses and workforce
    Diagnostics and decision support
    24/7 versus local
    Facilities, equipment and co-ordination
  • 6. 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
  • 7. 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.
  • 8. The new challenge
    No change!
    Add £13m
    £82 each
    Say £500 per family
    And this in only 25% of the health budget
  • 9. Needs are changing
  • 10. What should we be dreaming about today to meet this challenge
  • 11. Imagineering
    b. 1928, lives forever
  • 12. Integration is part of the solution
    Excite, delight, simplify
  • 13.
  • 14.
  • 15.
  • 16. Experience is growing
  • 17.
  • 18. 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
    Orthopaedic Pathway
    End of life care Training
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. What does it mean for us?