E HEALTH – ENABLING HIGH QUALITY AND CO-ORDINATED CARE FOR PEOPLE LIVING WITH LTC’s

CONTENT

1. Some key challenges

2. Integrating Care – supporting MDT’s

3. Reshaping delivery of Older People’s Care

4. E Pharmacy current and future opportunity

5. The benefits

HEALTHCARE DEMAND IS GROWING

Demographic change for population aged 65+ ScotlandPotential impact on emergency bed numbers 2007-2031

0

2000

4000

6000

8000

10000

12000

14000

16000

Y/E Mar 2007 Projected2011

Projected2016

Projected2021

Projected2026

Projected2031

Year

Be

ds

A new NinewellsHospital by 2031!

Macro IntegratorNHS Tayside and Angus Council

724

10148

25372

72487LTC’sAsthma

6101COPD2056

Diabetes4698

HBP16423

CHD5318

LEVEL 1HEALTHY

COMMUNITIES

2%LTC

Population

LEVEL 2SUPPORTED SELF CARE

VIRTUALWARD

ANTICIPATORYCARE PLANS

PATIENT PASSPORTS

CASEMANAGEMENT

LEVEL 4INTENSE

CASE MANAGEMENT

LEVEL 3CASE

MANAGEMENT

PRO-ACTIVECONTACT

SUPPORTINGSELF CARE

70%LTC

Population

28%LTC

Population

66%Overall

Population

Obesity11854

PRO-ACTIVECONTACT

SUPPORTINGSELF CARE

North West

187

North West

2631

North West

6577

North West

18790

North East

191

North East

2673

North East

6684

North East

19096

South

346

South

4844

South

12111

South

34601

ANGUS CHP – PATIENT PROFILE

Virtual Wards focusing on Tier 4 , Innovative Step Down Services are key to success!

Project DefinitionStatement

Benefits Statement

Project Status Report

ENSURE OUTCOMES ARE DELIVERED….

Is used for:

1. Stating your case for change

2. Current state analysis

3. Evidence / Data4. Envisaged Change5. Summarise

benefits

Is used for:

1. Define benefits in detail

2. Define appropriate measures

3. Summarise enabling changes ( PP&T)

4. Summarise milestone tracking

Is used for:

1. Report on delivery progress.

2. Report on Benefits Realisation against plan.

3. Escalate to Project Board or EMT for decision, support etc

Multi- disciplinary Project Board, Clinical and Finance essential

RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 1

Programme No Outcome 1

Outcome 2

Outcome 3

Outcome 4

Outcome 5

Outcome 6

Outcome 7

Outcome 8

Outcome 9

Outcome 10

Maintain people at home

Avoid Social Admission

Reduction in hospital admission

Avoid re-admission

Avoid DelayedDischarge

Reduced Bed Days

Reduction in Acute Beds

Reduction in Care Home placement

Reduction in Care Home admissions

Reduction in acute psychiatric beds

W1 Housing with care P1

W1 Effective assessment in community

P2

W1 Continuing Care in Care Home

P3

W1 Telehealthcare P4

W1 At risk assessment and support

P5

W1 Integration P6

W2 Improve service for people living with Dementia

P7

W2 Enhance OT & Equipment Service

P8

W2 Carer Support P9

W2 Capacity Building & Co-production

P10

W2 Improved models of public information

P11

Programme No Outcome 11

Outcome 12

Outcome 13

Outcome 14

Outcome 15

Outcome 16

Outcome 17

Outcome 18

Outcome 19

Outcome 20

Reduction in emergency respite placements

Improved quality of life for patient and carers

Improve service user and carers health

Improved Efficiency

Sustainable joint workforce with right skills mix

Reduction in building costs

Integrated assessment framework

Build community resilience

Develop social enterprise

Increased choice

W1 Housing with care P1

W1 Effective assessment in community

P2

W1 Continuing Care in Care Home

P3

W1 Telehealthcare P4

W1 At risk assessment and support

P5

W1 Integration P6

W2 Improve service for people living with Dementia

P7

W2 Enhance OT & Equipment Service

P8

W2 Carer Support P9

W2 Capacity Building & Co-production

P10

W2 Improved models of public information

P11

RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 2

TECHNOLOGY ENABLING INTEGRATED CARE

Integration Platform

Acc

ess

De

vice

Use

r

Se

curit

y

Ap

plic

atio

ns

Clinical Portal

PMS GPCommunity

Health&Social

Virt

ual

Dat

abas

e

Se

rvic

e

Sta

ff ID

RB

AC

TELEHEALTH

Complex Case

Management

CaseManagement

Pro-activeContact

Prevention

Collaboration Tools

Clinician Manager Administrator Patient

TELECARE

PREDICTIVE RISK

BUSINESS ANALYTICS

IHI CARE CO-ORDINATION MODEL

Goals(G) Co-ordination(C)

ValueProposition

Family, associated assets

PATIENTIDENTIFICATION

OUTCOMES

For people with multiple

needsFamily Social CarePeer GroupsCarer/s Voluntary

Supporting with

enabling technology

Predictive RiskTools

GP SystemsCommunity Information

Systems

TelehealthTelecare

Performance Management

Business Analytics

Personalised Multi-channel interfacePerson Centred

CARE CO-ORDINATOR

ServiceDelivery

ServiceDesign

INTEGRATED CARE(VIRTUAL WARDS) - THE CHALLENGE

• Emergency admissions and associated bed days not hitting HEAT T12 target..

• Challenge around Health Population Management (HPM)

• Lack of effective collaboration between Health and Social Care

• Alignment of e Health with key HEAT T6-T12 outcomes

• Key improvement areas:

1. Reduce all age Emergency Beds

2. More effective HPM

3. Standard operating procedures

4. Effective MDT working

5. Effective medication concurrence

ePharmacy Programme

SUPPORTING THE NEW COMMUNITY PHARMACY CONTRACTAcute Medication Service eAMS (& ETP):

» eAMS enables the generation and delivery of 1.6M electronic prescription messages per week at all of Scotland’s 1000 GP Practices and used in all 1200 Pharmacies. This improves patient safety through assurance for patient and medication item selection and allows for significant efficiencies to be achieved in payment processing ( £3.2M+ pa in efficiency savings for National Services Scotland.)

Chronic Medication Service eCMS

» eCMS improves the care of patients with long term conditions through a systematic approach to their care, enables eligible people to register with a community pharmacy of their choice, to have a personalised Pharmaceutical Care Plan record created and monitored and to have ‘serial’ prescriptions to be created to cover up to a years worth of medication. The medication will then be dispensed and monitored in their registered pharmacy. Reduces patient visits to GPs and reduces the number of paper prescriptions plus improves medicines management & reduces the drugs budget.

Minor Ailment Service eMAS

» eMAS aims to support the provision of direct pharmaceutical care within the NHS by community pharmacists to members of the public with a common self-limiting condition. enables eligible people to register with a community pharmacy of their choice and have their common conditions treated, including prescribing, by their community pharmacist on the NHS without the need to visit a GP and enabled by a revolutionary remuneration process

LOOKING FORWARD TO A BETTER FUTURE

SOME IDEAS FOR THE FUTURE

Payment process

PatientRegistration

Service

ePharmacyMessage

Store

InformationServicesDivision

ePay rules engine

Scanning and message processing

PharmacyCare

Record

Complianceblister pack technology ???

Telepharmacy Electronic Dispensing and Payment Processing for NHS24, OOH Pharmacy & Pandemics – Trial withUniversity of Aberdeen

ECS PCRs

ECS + PCRs arethe makings of anational patient summary record

Remote Electronic Prescribing (iPrescribe) mobile prescribing and pharmacy services – prototype 2011/12

Delivering beneficial change and efficiency gains and using innovative ways of sharing, developing and implementing to benefit the full patient journey

End to End Medicines & Compliance Management in NHSS – better dispensing and Pharmacy care information systems…add secondary care ePrescribing and compliance product to provide a unique medicines management service improving patient care and reducing costs through reducing re-admissions to secondary care and managing the drugs budget

• Test of change demonstrators commenced March 2011 following introduction of PEONY2…

• Enabling technology being fully utilised

• Aligning with local improvement initiatives eg CMR in Angus, Case Management and ACP’s across Tayside..

• Envisaged benefits across Patient Access, Service Redesign and Patient Experience:

1. Drive effective attendance at A&E

2. Reduction in unscheduled bed days

3. Effective discharge models

4. Focus on the right patients

5. Increase value multi-disciplinary team time

6. Net CRES of £1.5-2.0m per annum.

NHS Tayside BSU Dashboard Test of Change

Safe Effective Timely

Efficient Equitable Patient Centred

INTEGRATED CARE(VIRTUAL WARDS) - THE BENEFITS

• Next future state workshop brought together over 70 integrated care professionals and patient groups…

• Followed up be local sessions in CHP areas…

• NHS Tayside worked with partners to develop new HPM toolset – PEONY2

• Test of Change Demonstrators set up in each CHP

• Wider collaboration with Social Care, Voluntary Sector and Social Care

• Align outcomes with LDP, HEAT and Reshaping of Older People’s services

INTEGRATED CARE(VIRTUAL WARDS) - THE APPROACH

SUMMARY

• A whole system approach is key..

• Identify high impact projects and prioritise resource..

• Fully align with LDP and national outcome requirements

• Quality improvement with associated CRES takes priority..

• Early engagement of whole system stakeholders essential..

• Build on best practice evidence and focus on reducing unwarranted variation…

• Small steps, quick wins…