integrated care management. population management model supported self care care management health...
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Integrated Care Management
Population Management Model
Supported Self Care
Care
Management
Health Promotion
Population wide prevention
Care coordination
Most Complex
Range of risk
Education
Education Lifestyle
What is Integrated Care Management ?
Proactive approach High risk patientsMedical/nursing/pharmaceutical/social
needs Undertaken by Qualified
ProfessionalSuitable trained and competent
What does it involve? Full assessment medical, nursing,
pharmaceutical and social care needs Develop personalised holistic care plans Involve patients and carers as partners Highly visible Lead role Secure services/ treatments modalities Teach pt/ carers monitor condition Maintain contact through hospital
admissions Cross boundary working
Potential Benefits
Better outcomes for individuals, their families, carers and communities
Improved access to services Reduction in the use of unplanned care Improved concordance with medication Improved partnership working Reduction in the number of professionals involved in
the individuals care Improved choice Greater continuity of support / care / involvement More control in the package of care / support
provided Improved and speedier decision making Empowerment of individual through active
participation in the process
Care Managers Training(Health Staff)
Advanced clinical assessment skills
Physical examination skills Minor Major Illness Injury
Nurse Treatment Service (MINTS)
Independent and Supplementary prescribing
Care Management Training
Lanarkshire Pilots 12 month pilots Outcome Measures
Admission rates, LOS, pharmaceutical care, GP attendances, clinical consultations, equipment, social care service utilisation, patient, carer, staff satisfaction
Most effective approaches rolled out across Lanarkshire
Lanarkshire Locality pilots
High Risk by Gender
High Risk : Total Bed Days used
High Risk group and number of Emergency Admissions
Emergency Admissions Vs Total Bed Days
Principal Diagnosis of High Risk
High Risk cohort by Probability
Probability Vs Diagnosis
SPARRA Outcomes in Lanarkshire
Coatbridge Clydesdale East Kilbride Total
Total High Risk 81 42 44 167
Deceased 26 14 8 48
Improvement in Health (Data Review) 28 0 18 46
residing in Long Term Care 7 3 9 19
Outwith Catchment areas 7 1 3 11
Palliative Care 1 0 0 1
Patient refused Assessment 0 4 0 4
Offered Full assessment 11 18 3 32
Accepted 8 10 2 20
Refused 3 8 1 12
Refusal Reason- Client refused 1 0 0 1 Improvement in Health 2 5 0 7 Unknown 0 3 0 3 Undergoing Assess LTC 0 0 1 1
SPARRA Outcomes
29%
29%
12%
7%
1%
2%
20%
Deceased
Improvement in Health(Data Review)
Residing in Long TermCare
Outwith Catchmentareas
Palliative Care
Patient refusedAssessment
Offered Fullassessment
38%
Offerred Full Assessments
62% (20)
38% (12)
Accepted
Refused
Refusal Reasons
1
7
3
1
0
1
2
3
4
5
6
7
8
Clientrefused
Improvementin Health
Unknown UndergoingAssess LTC
Shared Learning