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How can we co-ordinate care from
the information perspective
Experience from Carmarthenshire Chronic
Conditions Demonstrat...
Health and social care has tended to
create a series of
simple, disconnected, linear systems
each designed to maximise one...
…and yet we have the
knowledge, technology and imperative
to formulate a sustainable way of
delivering services rather tha...
Building the
CCM Model
Predictive Risk
Tool
Telehealth and
Telecare
Generic CCM
support worker
Generic Care
Pathway
Core M...
Ecosystems are
complex, interconnected and
interdependent and designed
towards an optimised overall system
From information to understanding
CCM model and framework: role of
care co-ordination
• Identify, plan and co-ordinate services to meet
needs at each of the...
Confusion!
Views on the Care Co-ordinator role:
• The person who took the lead in ensuring the
Unified Assessment process ...
Clarification
Analysis of Skills for Health competencies for care
co-ordination, care management and case
management:
• 15...
Care Co-ordinator
became
Care Services Planning Co-ordinator
Based on mid year estimates 2008 population growth & 2008/09 QoF as a
% of the total registered population 2009
Planning: ...
Planning and co-ordination: service utilisation
Emergency medical admissions
EMAs by Chronic Disease; Carmarthenshire Resi...
Planning – population and individual:
predictive risk tool
Locality workforce profile
Individual care co-ordination: care plan
Planning and care delivery: health and social
care directory of services
Information to support others: multi-
disciplinary team meetings
Planning and delivery: chronic conditions
generic care pathway
Chronic conditions – average length of stay:
measuring achievement
F
eb
-0
8
D
e
c-0
7
O
ct-0
7
A
ug
-0
7
Jun
-0
7
A
p
r-0...
From information to understanding:
our integrated community services care model
Care Services Directory Menu
Carmarthenshire Community Services Care Model
Identify Cases Initiate Care Process Care Deliv...
Integrated, comprehensive solution that addresses
multiple challenges simultaneously and coherently.
Rhayader Home Support Service
You never change things by fighting the existing
reality. To change something, build a new
model that makes the existing m...
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Leo Lewis: co-ordinating care from the information perspective

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Leo Lewis, Senior Fellow at the International Foundation for Integrated Care, draws on experience from the Carmarthenshire Chronic Conditions Demonstrator programme in Wales, to look at the key elements necessary to deliver effective services for people living with, or at risk of developing, chronic conditions.

Published in: Health & Medicine, Business
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  • Transcript of "Leo Lewis: co-ordinating care from the information perspective"

    1. 1. How can we co-ordinate care from the information perspective Experience from Carmarthenshire Chronic Conditions Demonstrator, Wales Leo Lewis Senior Fellow International Foundation for Integrated Care
    2. 2. Health and social care has tended to create a series of simple, disconnected, linear systems each designed to maximise one goal…
    3. 3. …and yet we have the knowledge, technology and imperative to formulate a sustainable way of delivering services rather than pursuing approaches that simply mitigate negative impacts.
    4. 4. Building the CCM Model Predictive Risk Tool Telehealth and Telecare Generic CCM support worker Generic Care Pathway Core MDT CCM Teams Locality GP Clusters Care Co- ordinator CCM Model – population based c50,000
    5. 5. Ecosystems are complex, interconnected and interdependent and designed towards an optimised overall system
    6. 6. From information to understanding
    7. 7. CCM model and framework: role of care co-ordination • Identify, plan and co-ordinate services to meet needs at each of the model’s four levels • Liaise with patients, carers and service providers from private, voluntary, statutory and independent agencies • Monitor patient progress and service delivery across primary, secondary, community and social care • Co-ordinate primary care collaborative networks and networked services • Advise on the commissioning of chronic conditions services
    8. 8. Confusion! Views on the Care Co-ordinator role: • The person who took the lead in ensuring the Unified Assessment process was implemented for service users – either health or social services • Case Manager • Care Management • Community Chronic Disease Management Specialist Nurse
    9. 9. Clarification Analysis of Skills for Health competencies for care co-ordination, care management and case management: • 154 competencies delineated into three functional areas: – Strategic co-ordination and planning at a population level – Clinical/social care co-ordination focused on delivery of services to individuals – Data and information competencies to support other roles
    10. 10. Care Co-ordinator became Care Services Planning Co-ordinator
    11. 11. Based on mid year estimates 2008 population growth & 2008/09 QoF as a % of the total registered population 2009 Planning: chronic condition prevalence Projected Over 75 years QoF Events by disease 2009 to 2014 & 2019 Towy Taf Locality 622 408 2823 254 1110 1369 281 252 521 742 39 339 65 628 689 503 493 695 456 3155 284 1241 1530 314 282 582 829 44 379 73 702 770 562 551 812 533 3687 332 1450 1788 367 329 680 969 51 443 85 820 900 657 643 0 500 1000 1500 2000 2500 3000 3500 4000 AF Asthma BP Cancer CHD CKD COPD Dementia Depression (diagnosis) DM Epilepsy HF MH Obesity Stroke/TIA Thyroid Population>75 /10 QoF Disease area Numbersofpatients 2009Evts>75 2014 Evts>75 2019 Evts>75
    12. 12. Planning and co-ordination: service utilisation Emergency medical admissions EMAs by Chronic Disease; Carmarthenshire Residents 0 100 200 300 400 500 600 700 800 900 COPD HF Diabetes All Type 1 Type 2 Other Diabetes Condition Number Calendar Year 2004 Calendar Year 2005 FY 06/07 FY 07/08
    13. 13. Planning – population and individual: predictive risk tool
    14. 14. Locality workforce profile
    15. 15. Individual care co-ordination: care plan
    16. 16. Planning and care delivery: health and social care directory of services
    17. 17. Information to support others: multi- disciplinary team meetings
    18. 18. Planning and delivery: chronic conditions generic care pathway
    19. 19. Chronic conditions – average length of stay: measuring achievement F eb -0 8 D e c-0 7 O ct-0 7 A ug -0 7 Jun -0 7 A p r-0 7 F eb -0 7 D e c-0 6 O ct-0 6 A ug -0 6 Jun -0 6 A p r-0 6 10 9 8 7 6 Month Days _ X=6.817 UCL=7.446 LCL=6.188 1 6 5 5 1 Rolling 12 Months' Average Length of Stay COPD Emergency Admissions I Chart of Carmarthenshire by Month Fe b -0 8 D e c-0 7 O ct-0 7 A u g -0 7 Ju n -0 7 A p r-0 7 Fe b -0 7 D e c-0 6 O ct-0 6 A u g -0 6 Ju n -0 6 A p r-0 6 5.75 5.50 5.25 5.00 4.75 4.50 Month Days _ X=4.813 UCL=4.971 LCL=4.656 Rolling 12 Months' Average Length of Stay CHD Emergency Admissions I Chart of Carmarthenshire by Month Source: HSW Web Indicators SaFF 10 (Target 5.7 days)(Target 5.7 days)
    20. 20. From information to understanding: our integrated community services care model
    21. 21. Care Services Directory Menu Carmarthenshire Community Services Care Model Identify Cases Initiate Care Process Care Delivery and ReviewCare Assessment and Planning Information Point for Citizen, Carer, and Professional Single Point of Access 24/7 Response Unplanned Referral Initial Referral Generate Intervention Requests Diagnostic Intervention Assess Planned Community Services Intervention Urgent Community Services Intervention Review and Assess Case Finding Self Referral Allocate Key Worker Enter Referral Unplanned Community Services Intervention Unplanned Intervention – (not CS) Re-allocate Prism and PARR++ GP Registers Case Lists Activity Reports Assessment & Prioritise Update H&SC Records Update H&SC Records Update H&SC Records Escalate to Community MDT Team Escalate Main CCM Delivery Providers include: Social Care, District Nursing, Canllaw, DRT, CDM, General Practices, Out of Hours, Ambulance Trust, Voluntary Sector, Independent Sector, ART , TC/TH Integrated Health and Social Care Register Discharge Community MDT Team Update H&SC Records Produce Care Plan Planned Intervention – (Not CS) Normal Unplanned Info Resource Normal Path Unexpected Path
    22. 22. Integrated, comprehensive solution that addresses multiple challenges simultaneously and coherently.
    23. 23. Rhayader Home Support Service
    24. 24. You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete. Michael Pawlyn 2013
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