Royal Free London NHS Foundation Trust

Royal Free London
NHS Foundation Trust
Our Integrated Care Journey
Dr. Alexandra Wu
Clinical Director
Service Transformation
The Royal Free
Integrated Care Journey
Scope and Contents
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What is integrated care?
Why do integrated care?
What is involved?
How did we do it?
What did we learn?
How did we evolve from our learning?
Summary and conclusions
Questions & Answers
The Royal Free
• Licensed as a Foundation
Trust since April 2012
• Merged with Barnet and
Chase Farm Hospitals
(July 2014)
• £1 Billion turnover
• 10,000 full-time staff
• 1100 beds approximately
• Teaching hospital and a
tertiary with district
general function
1. What is integrated care?
• Meeting the needs of individuals by flexible and
seamless working across multiple organisations to
deliver optimal and personalised care whether in
hospital or at home
• This is a collective responsibility between the
primary and secondary sectors.
2. Why do integrated care?
• Current economic environment for the NHS
• QIPP - Imperative is to achieve ‘best in class’
clinical productivity (length of stay, re-admissions,
excess bed days)
• Clinically led pathway redesign focused on patient
cohorts
• Results in length of stay reductions and admissions
avoidance
3. What’s involved
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Two innovations in September 2010
– Post Acute Care Enablement (PACE)
– Triage Rapid Elderly Assessment Team (TREAT)
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Patient cohort
– Complex, elderly patients
– Urgent care division
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Department involved
– Health Services for Elderly People (HSEP)
– 3,200 emergency admissions/year, 40% of acute take
– Chronic long-term conditions, care homes, variable acuity
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Aim to deliver a different model of care
– Reduce admissions
– Early support discharge
– As safe and as high quality but in a lower cost setting
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Funding and resources
– Closure of 18 bedded acute medical ward to re-direct funding for the innovations
– Appointed Dr. Alexandra Wu as clinical champion and Kam Karilai as project
manager under the direction of Katie Donlevy, Director of Integrated Care
4. How did we do it?
• Brainstorm with multi agencies in May 2010
• Build relationships, establish capabilities and facilities available
• Identify patient groups and wards
• Map out patient’s pathway, define process and logistics
• Define joint clinical governance with clear roles and responsibilities
• Agree data collection criteria
• Estimate staffing requirements
• Define outcomes and performance measures
• Set up steering team (led by clinical champion) and weekly meeting
• Agree timeline for implementation, starting in September 2010.
POST ACUTE CARE ENABLEMENT
(PACE)
8
What is PACE?
• Early supportive discharge service
• Later part of an acute episode delivered in an out of hospital setting
• But still under auspices of the acute team
• On site community case finders integrate with acute team to ‘Pull’
patients
• Patient no longer requires 24hour inpatient medical care
• Patient has on-going nursing & medical monitoring needs that can
be safely met outside of the hospital environment
• Content of care more medical and intensive than traditional
intermediate care
• Provider to provider collaboration
An Integrated
model of care
linking with the
community
Increased
patient choice
Reduced
number of
Admissions
Reduced
Length of Stay
Beds closed
as a result
Delivering high
quality care
at a lower cost
Aim of PACE
• Provide an integrated model of care linking with the
community
• Increase patient choice
• Reduce number of admissions (supporting admission
avoidance team TREAT)
• Reduce length of stay
• Make bed day savings
• Deliver high quality care at a lower cost
Royal Free PACE
• Provider to provider
collaboration:
– RFH
– Barnet Community Services
– Camden Provider Services
– London Boroughs of Barnet and
Camden
Where PACE acts in the urgent care pathway
Community
Urgent Care Centre
Clinical Decision Unit
(Triage Rapid Elderly Assessment Team)
Admission Avoidance
PACE
TREAT
MAAU (72 Hour Stay)
Base Wards
Community
PACE and TREAT pilots started in September 2010
PACE
Accident and Emergency
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Sample case
Elderly man
Septic
Acute urinary retention
Faecal impaction
Reduced mobility
Needs increased care package
Management plan:
PRE PACE
Day 1 Catheterisation
Bowel clearance
Intravenous antibiotics
Day 2 Physiotherapy & Occupational Therapy assessment
Social services review
Day 3 Trial without catheter
Day 4 Observations for improvement
Wait for care package
Day 5 Discharge – MAY BE?
PACE
Day 1
HOME
What does PACE affect?
Key:
- Optimal LOS
- Actual LOS
Number of patients
PACE
Length of stay (LOS) in bed days
Conditions Suitable for PACE
• Exacerbation of COPD
• Faecal Impaction/ Urinary retention
• Simple infections- Cellulitis , UTIs
• Deep Vein Thrombosis
• Falls
Low Acuity Patients
• Diabetes
• All of the above + cognitive impairment
Typical PACE Patients Monitoring
• General observations including Postural Blood Pressure, Peak
Flow, Oxygen Saturation, Blood Sugar Monitoring etc.
• Blood Tests including INR
• Administer medications including enemas & IV antibiotics
• Monitor medication & titrating analgesia
• Bowel care
• Catheter care and bladder scanning
• Wound care
• Ambulatory 24 hour ECG
• ! Assess daily & Escalate : Signs of deterioration
• ! Signposting
The clinical model
• Daily MDT board rounds (clinical champion present)
• Patients identified by medical team and on site ‘pulling’ case finders
(senior experience community staff)
• Comprehensive assessment undertaken
• Clear follow-up and escalation process in place
• Patient goes home within 4 hours of acceptance onto PACE
• All onward social care needs managed by PACE team
• Up to 5 days input (flexible) and clinical responsibility remains under
discharging team
Implementation
• Must be clinically led & driven - CHAMPIONS
• Focus on few cohorts with high gains e.g. frail elderly
• Agree evaluation measures up front and make sure you capture the
data
• Create the evidence base as the service develops
• PACE will surface operational issues requiring weekly meetings
• Improve by pathway mapping
• Marketing - engage and communicate with patients or clinicians
(RFH and GPs)
• Educate – road shows, workshops and work alongside
Data and Outcome Measures
• Health Resource Group (HRG)
• Attendances
• Admissions
• Length of Stay (LoS)
• Re-admissions
• Patient satisfaction
• Clinical Incidents and Discharge Alerts
Evaluation of RFH PACE
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Patient satisfaction high
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Beds closed as a consequence – LOS reduction average 3 days per patient
Week 234 ( Feb 2015)
Borough
Barnet
Camden
Referred
4255
4654
Accepted
2995
3142
Discharged
2927
3090
Readmitted
92
153
Summary
Total Patients Referred
8909
Total Number of Patients Accepted
6137 (69%)
Total Number of Patients Discharged
6017 (98%)
Total Number of Patients Re-admitted (5 days)
245 ( 4%)
All patients with PACE
diagnosis
Length of stay now
Management Support
• Monthly PACE Operational group:
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Alex Wu (chair, Clinical Director Service Transformation),
Fran Gertler (Head of Integrated Care)
Kam Kalirai (Associate Director of Service Improvement)
Community MDT
• LOS and QIPP Steering group:
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Katie Donlevy (Director of Service Transformation)
Kate Slemeck (Chief Operating Officer)
Janet Mustoe (hospital director)
Operations and nursing managers
• Data Analysts/Administration support
• Funding
T.R.E.A.T
Admission
Avoidance
 Avoid admissions through rapid multi-disciplinary assessment and
treatment
 7 days a week consultant led service based in A&E
 Rapid access investigations and interventions.
 Emergency Social packages
 Work proactively with GPs, community teams and care homes
 Return patients safely to the community
 Specialist nurses- triage/outreach
 Enhanced patient experience supported by post-discharge follow-up
phone call
T.R.E.A.T
Admission
Avoidance
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‘Hot Clinics’
‘Hot Lines’
Set up on a daily basis
Responsive to urgent referrals
Aim to avert crisis leading to hospital admission.
Rapid multi-disciplinary review
Rapid communication with primary care
Hot lines manned by consultants
SINGLE POINT OF CONTACT
Prepared by Kam Kalirai Head of Service Redesign 190511
TREAT results
No. of patients
2011/2012
2012/2013
2013/2014
1614
2461
2306
Suitable for
TREAT
584 (30%)
863 (35%)
866 (37%)
Discharged by
TREAT
477 (82%)
628 (78%)
621 (72%)
Discharged with
PACE
216 (45%)
289 (48%)
268(31%)
Triaged
Rapid Response started
• Reduced length of stay
• Patient satisfaction extremely high
• Has now attracted substantial commissioner funding
New TREAT team
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6 consultant geriatricians
2 acute specialist nurses (Band 6 and 7)
2 community specialist nurses (Band 6)
2 juniors doctors F2/ST/SpR
Occupational therapist
Pharmacist
Social Services
Administrator and data analyst
PACE/ RAPID RESPONSE TEAM
5. What did we learn?
BEFORE - The urgent care pathway
Community
Urgent Care Centre
Clinical Decision Unit
(Triage Rapid Elderly Assessment Team)
Admission Avoidance
PACE
TREAT
MAAU (72 Hour Stay)
Base Wards
Community
PACE and TREAT pilots started in September 2010
PACE
Accident and Emergency
What we’ve learnt - 1
TREAT
ADMISSIONS
PACE
LENGTH OF STAY
Increase patients’ choice of care
Lay foundation for integrated care
Increase capacity for new business
What we’ve learnt - 2
TREAT
ADMISSIONS
PACE
LENGTH OF STAY
A&E ATTENDANCES
We need more than just
PACE and TREAT to drive
these down
RE-ADMISSIONS
(30 days)
6. How did we evolve from our learning?
AFTER - New Integrated Health Care System
Extending into the Community
Community Hub
Attendance
Prevention
Frailty screening
Target re-attenders
Consultant-led
Assessment &
Discharge
Co-ordination
Fast Diagnostics,
Clear Outcomes,
Get it right first time
E
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Purpose:
- Case management MDT
- Multi-specialty clinics
- Identify gaps in care
Players:
- GPs
- Consultants
- Therapists
- Social Services
- Community Matrons
- Mental Health Teams
A&E Rapid Assessment Triage (RAT)
A&E (4 hours)
Urgent Care Centre
Admission Avoidance (TREAT) + HOT Clinics
23 hour Emergency Assessment Unit
Medical Admission
Unit (72 hours)
Surgical Admission
Unit (72 hours)
R
R
T
P
A
C
E
Care Home
Medicine
Outreach
Domiciliary Visits
Elective
Ambulatory Care
Unit (PITU)
Day Surgery Unit
Base Ward (>72 hours)
Robust Administration, Data Collection & Quality Outcome Measures
How we need to evolve
Care Navigation Service
Community Hubs
Care Home Outreach
ADMISSIONS
TREAT and PACE
LENGTH OF STAY
Urgent Care Centre
A&E Re-design
Emergency Ambulatory Care Unit
A&E ATTENDANCES
Elective Ambulatory Care Unit (PITU)
Day Surgery Unit
RE-ADMISSIONS
(30 days)
We need all the above components to achieve these targets
Next Steps for the Royal Free (1)
FRONT END REDESIGN
• new A&E /Urgent Care Centre ( £23 million)
• co-locate with a consultant led Emergency Ambulatory Care unit
• Expand across whole trust concept of ADMISSION AVOIDANCE
ASSESS TO ADMIT
HOT CLINICS
PACE / RAPID RESPONSE
• Increase productivity of ELECTIVE AMBULATORY CARE UNIT (PITU)
NEW DAY SURGERY UNIT
• Consolidate CARE NAVIGATION SERVICE
community hubs
multi-disciplinary clinics
case management
• Develop CARE HOME MEDICINE with consultant-led outreach team targeting attendance
prevention and admission avoidance
• Re-design CLINICAL PATHWAYS, incorporating community resources, PACE / RAPID
RESPONSE
Current Cellulitis Pathway
Referral routes
A&E
Register
patient in
Cerner
Patient
assessed in
A&E
Does pt
needs
Admission
Patient treated
in A&E
YES
GP
Patient
assessed in
A&E by medical
team
Medical
Expected ID or
other speciality
Patient treated
in A&E
OPD Clinics
Hot Clinics
Register
patient in
Cerner
Patient
assessed in Hot
Clinic
Patient Treated
in Hot Clinic
Plastics
ID clinics on
Thursdays
Register
patient in
Cerner
Patient
assessed in ID
clinic
Patient Treated
in ID clinic
Dermatology
Dermatology?
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Scleroderma
Rheumatology
Dermatology
Heart Failure
Community
Hubs
Camden and
Barnet
Pt given oral
antibiotics and
home
Pt given oral
antibiotics and
home
A&E
Ambulatory
first dose given
in A&E
Patient attends
Daily for 2ND & 3rd
dose given in GQ
clinical review
PACE
Ambulatory
first dose IV
given in A&E
Discharged to
PACE
Request a bed
YES
Has
patient
responds
to iv
NO
Patient referred to
ID 15% admitted
Diabetic Foot
Vascular
NO
Vascular ?
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OPATS 11 West
day case ID
Thursday
Currently there are several pathways for different specialties treating patients
with cellulitis which has resulted in ;
 A range of different protocols
15% of patients with cellulitis in seen in A&E are admitted and 85% of patients
are discharged home or are on an ambulatory pathway
When admitted, patients have a mean hospital stay of 5 days (patients aged
65 years or over stay 7 days on average)
40% of the patients with a significant clinical comorbidity
These account for 62% of the cellulitis bed days demonstrating that long
length of stay is associated with factors other than the cellulitis diagnosis and
is affected by other underlying conditions.
Streamlined Cellulitis Pathway
The A&E/23hr clinical redesign team have designed an integrated cellulitis pathway
supported by a simple treatment algorithm to reduce variation in clinical practice.
GP
Community Hubs
Camden and
Barnet
Stevenson House
Finchley
Memorial
A simple Algorithm
Patient checked in
and triaged in A&E
(TELE- MEDINICE)
A&E/Urgent Care
assessed and
treated as pre
agreed
ALGORITHM
Does pt
needs
Admission
NO
YES
23 hour unit leads
admission
Ambulatory 23 HR
Hot Clinics for IVs and
medical review for
ambulatory pt
PACE for nonambulatory patient
and needs IV
antibiotics for up to 7
days but not admission
OPD Appointment in
PITU/OPATS for
patients with long
lines
Finchley Memorial
community infusion
hub for review and IV
Discharge home oral
antibiotics
PACE (Short duration IVs up to Seven days for immobile patients)
OPATS in PITU for patients with long lines and longer than 14 days antibiotics
Patient
discharged home
Patient admitted
to MAU
Patient admitted
to a Base Ward
Patient
discharged home,
+ /-PACE
+/- PITU OPATS
Next Steps for the Royal Free (2)
•Extend the PACE &TREAT model for other specialities & our newly merged Trust
• PACE delirium/dementia
• PACE surgical (colorectal and vascular)
• PACE specialist services (infectious diseases)
• PACE rehabilitation
• PACE renal medicine
• Use of voluntary services to follow up PACE discharge
• Build an integrated IT system to provide real-time patient information
• Robust training programme established focusing on practical skills & acute
medical problems
• Create joint primary (GPs) & secondary care appointments
• Marketing - conduct regular workshops & GP forums to create awareness
• Evaluation, research & consultancy
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7-DAY WORKING
oDrop in to meet & talk to specialist nurses
oAsk questions about policies & practices
oFind out more about competencies
oSupport your PREP requirements
oPractice your clinical skills
oCheck your knowledge & skills
oSeek advice and support
oPick up some literature
Many specialist nursing teams will be available on the day:
Infection control
Nursing directorate
Urology nurses
Blood transfusion
Stoma nurses
Dementia nurse consultant
Continence nurses
& many, many more....
Medical electronics
Palliative care
Diabetes nurses
More
information
to follow...
7. Summary & Conclusions
Integrated Care - Summary & Conclusions
Making integrated health care system works take years not months. The true
value of the new Integrated Health Care System is about developing
partnerships and new ways of working, delivering good patient outcome
and value for money in the long term.
Value
Good patient outcome
Enhanced patient
experience
Avoidance of
inappropriate or
unnecessary hospital
based activities
This takes years and
subject to evolution!
A champion is essential
Value for money
Years
Clinical
Communications Eliminate
Champions &
&
Service
Strong
Marketing
silos
Operational
Management
& Governance
Education
&
Training
Integrated
IT
System
Data
Analysis
& Research
LEARNING POINTS
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Champions – Grow your own and clone them !
Marketing
Educate – Work alongside
Learn from the best
Spot the gaps and evolve
Tough on data / clear on process
Ask daily – What can be done better? And it
can be done!
• Don’t give up too soon
Thank You
Questions?