promise proactive management and integrated services for the elderly promise the bromley programme...
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PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
ProMISEThe Bromley Programme
Sam Merridale, Programme LeadJune 2012
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Local Context
• Large ageing population >16% in 2011• Diabetes, cardiac and respiratory commonest
cause of ill health• Carers and dementia probably under
recognised• Current service delivery often fragmented &
reactive
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Vision
Improve the health of our older population with complicated health &
social needs in Bromley
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Goals
• Inform patients and promote independence• Identify most vulnerable & over 65• Design care plan around the patient’s needs• Manage their care through coordinating
services effectively
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The Objectives
• Develop a tool to identify most vulnerable• Create a cohort of people “virtual ward”• Design patient-centred care-plan• Deliver quality service-coordinated, targeted
and appropriate• Promote self-care and education for patient &
carers• Improve communication between care-givers
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Outcomes
• Improve clinical outcomes, reducing unplanned admissions and length of stay in hospital
• Improve patient’s experience, broadening their understanding of their health needs and self-care measures
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Developing a Culture Shift
• Key driver is to improve care for our older population
• Need for better respect, improved understanding, shared commitment, opportunities for learning & support->
effective collaborative working
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
The next step-Phase One
• 2 community matrons & 2-3 GP Practices• Testing out the pathway with existing services• Results & progress will inform and enable us
to improve and refine services based on active cases
• Start education programme in primary care
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Programme Implementation
• Managed process• Programme management team – meet weekly• Agree programme structure, priorities and
case for change• Engagement – critical to success
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Programme Governance
• Programme Board – responsible for all decisions and moving the programme forward
• Clinical Advisory Group• Stakeholder Reference Group• Programme Implementation Group
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Accountability
• Health and Wellbeing Board – Financial oversight of shared budget
• Bromley Clinical Commissioning Executive• Bromley, Bexley, Greenwich Programme –
Clinical Strategy Group
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Stakeholder Engagement
• Primary care clinicians• London Borough of
Bromley• Bromley Healthcare• South London Hospitals
NHS Trust• Oxleas Trust• London Ambulance
Service
• Bromley Links• Bexley CCG• Greenwich CCG• NHS SL Cluster• St Christopher’s• Voluntary Sector• EMDOC• … etc
PProroMISEMISEProactive Management and Integrated Services for the ElderlyProactive Management and Integrated Services for the Elderly
Interesting issues!!
• Case finding – using risk stratification, but also clinical knowledge
• Data sharing – across organisational boundaries, and critical to success
• Metrics for evaluation – must be consistent with others
• Telehealth – explore the principles of how this will support true integrated care – it’s not just about expensive gadgets