5th feb ccg presentation


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  • 40 million don’ t have healthcare in America, 1960 act Medicare, ensured over 65 , all states must provide healthcare whether pts. can afford or not There is no one system for people but a mish mash of systems, Leadership, integration, quality No quick answer, need to develop culture and policies will catch up
  • Clinical assistant per adult physician, call pts., screening, 18% pt. readmission at 30 days, 30% at 90 days. 75% preventable Critical decision unit, pharmacy, radiology, 24 hour assessment, not a/e , has on site case manager to provide guided care if likely hood of admission No social care
  • Serves 90,000 enrolled veterans in 2011 there where 1.1milion pt. encounters at hospital Community based out outpatient clinics, access to telehealth Women’s health clinic
  • Integrated system across all areas, with access to investigations, apt systems. Photo on the screen of the pt., In separate folders but ability to access if you are responsible for that pts. care.
  • Learning is an active verb No incentives but lots of data instead, Culture of excellence
  • Primary care seems essential, unlikely to improve quality and bend cost without sub-subspecialties involved Aligning forces within delivery service
  • 5th feb ccg presentation

    1. 1. Leadership For Integration
    2. 2. Who is involved with the project. Partnership Organisations ∗ Cheshire East Council Name of Leads ∗ Cheshire West Council ∗ Andrew Spooner - GP Lead ∗ Cheshire & Wirral Partnership Trust ∗ Jonathan Griffiths - GP Lead South Cheshire Health ∗ Shirley Hammersley - Consultant ∗ East Cheshire Trust – Cheshire∗ Susan Ikin – Commissioning Business unit Manager ∗ Mid Cheshire Hospital FT ∗ Zoe Ahearne – Community ∗ North West Ambulance Service Matron ∗ NHS South Cheshire CCG ∗ NHS Vale Royal CCG
    3. 3. The Journey ∗ Team ∗ Personal
    4. 4. Aims∗ Patient centred care (as opposed to disease centred care) with guides to help around the system∗ Achieving primary care focussed service∗ Patient care delivered in an appropriate part of the system∗ Every person or service doing their own job well -∗ Encouraging and measuring features to work together and work separately∗ Generic understanding of how to do this for later dissemination and use
    5. 5. Violet• 66 year lady, lives with husband (who has some memory loss)• Has diabetes and heart failure, arthritis• Has many agencies involved, GP,CM, DN, physio, OT, S.W. continence services• Regular changes in condition; leg oedema, dizziness, breathlessness, poor renal function, constipation,• Wants to live a active life.
    6. 6. NHS Outcome Framework (2013-2014) Prevent people from dying prematurely Enhancing quality of life for people with LTC Helping people to recover from episodes of ill health or following injury Ensuring that people have a positive experience of care Treating and caring for people in a safe environment; and protecting them from avoidable harm
    7. 7. Integrated Care∗ Care co-ordination∗ Improving primary care management of patients with both mental and physical health needs through to end of life,∗ Effective medicine management∗ Managing ambulatory sensitive conditions∗ Active support for self management
    8. 8. Examples∗ Torbay∗ Northwest London integrated team pilot∗ Bolton diabetic care∗ Wolverhampton heart failure service∗ Wales Chronic Care Demonstrators
    9. 9. In practice …. Fear of 1% Should not prevent the benefits for 99%
    10. 10. Veterans Affairs Medical Center
    11. 11. PACT Teamlets∗ Teamlets consistent of ∗ Primary Care Provider ∗ Registered Nurse* ∗ Health Technician* ∗ Clerical Staff Person*∗ Each member of the teamlet works to the top of their licensure∗ Optimal functioning of the teamlets depends on the presence of all of these team members∗ * designates team members who are not present in all teamlets
    12. 12. Access
    13. 13. Challenges∗The Big Picture∗ Bringing together primary, secondary care∗ BIG scale change∗ Aligning services around the needs of the person not the organisation
    14. 14. Change
    15. 15. What Do We Want To Achieve? The Accountable Care Organization is like The Unicorn. Amythical beast with power to cure all our problems, but whom nobody has ever seen . ( A blind man is constructing the unicorn)