Person centered coordinated care: reducing LOS, DTOC

Report
Currently managing of 10.8 million lives
across the UK & Canada
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The Rotherham NHS
Foundation Trust
Integrated Care
What’s in a name……
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The Rotherham NHS
Foundation Trust
Today, 175 definitions of “Integrated Care”
(Kings fund)
• Integration [definition]:
Person centered coordinated care*
(National Voices)
• “My care is delivered from people who work
together to understand me and my carer(s)
needs, and coordinate services to achieve my
best outcome”
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The Rotherham NHS
Foundation Trust
Innovation driving integration?
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The Rotherham NHS
Foundation Trust
Interoperability:
diverse systems working together
3rd
sec
Vol.
Sev.
LA
Data
Hospital
PAS
GP
System
Comm.
System
Moving DATA between services & settings
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The Rotherham NHS
Foundation Trust
Integration:
Person centered coordinated care
Moving PATIENTS between services & settings
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The Rotherham NHS
Foundation Trust
Strata connects the entire network of providers;
ensuring the patient’s journey is planned &
monitored; creating a truly shared approach
Moving PATIENTS between services & settings
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The Rotherham NHS
Foundation Trust
…so many care pathways, what is safe?
Age
Concern
Social
Care
Long Term
Care
A&E
Health
Visiting
MAU
Hospital
Deal or no
deal ?
Rapid
Response
Addictions
Socialization
District
Nursing
Mental
Health
Religious
Support
Village
Support
End of
Life
Bereavement
Counseling
Community
Services
OT
Assisted
Living
PT
The Rotherham NHS
Foundation Trust
But an insurmountable task?
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The Rotherham NHS
Foundation Trust
No, very much within the
‘Art of the Possible’!
• ‘Process’ defines ‘outputs’ - no panacea
• Need a framework that underpins local best practice
process
• Clinically lead, operational driven, & supported by IT
–
–
–
–
Bespoke needs of patients
Local Best Practice process & service delivery
Dynamic: expect change
CI culture: CHC/DST, reduce readmissions, social housing,
anti-coagulation, mental health
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The Rotherham NHS
Foundation Trust
System wide care coordination value proposition:
planned, transparent, consistent = QIPP
The Rotherham NHS
Foundation Trust
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The Rotherham NHS
Foundation Trust
NHS IMAS: 8 principles for patient flow
•
•
•
•
•
Early senior review.
Daily senior review.
Focusing on discharge.
Continuity of care.
Matching capacity to demand and reducing
variation.
• Internal professional standards.
• Ambulatory emergency care.
• Managing patient flow streams.
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The Rotherham NHS
Foundation Trust
Making Integration Happen: Kings Fund
• Developing integrated care means overcoming
barriers between primary and secondary care,
physical and mental health, and health and
social care to provide the right care at the
right time in the right place.
• Innovate in the use of commissioning,
contracting and payment mechanisms and use
of the independent sector
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The Rotherham NHS
Foundation Trust
Ever heard of this guy?
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The Rotherham NHS
Foundation Trust
Patient Flow…through the hospital
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The Rotherham NHS
Foundation Trust
Patient Flow through the entire system!
Local
CCG’s
Community
Volunteer
Authority
Services
Services
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The Rotherham NHS
Foundation Trust
System Wide Collaboration
RESOURCES MATCHING, CAPACITY, PULLING & PUSHING,
Status intervals, messaging, thresholds / breach driving KPI’s
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The Rotherham NHS
Foundation Trust
Actions during the patient journey / hand off facilitated by Strata
Access ALL
options on
patient
hand-off
DDA (2003)
replace
inefficient
transactions
Decision
Support
Increasing
plurality of
Provision
Transactional
progression of
patient hand-off
Admission
criteria
bespoke to
local service
Dashboard
tasks &
waitlists
Interval time benchmarked
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Real time
Capacity a fx of
Process
The Rotherham NHS
Foundation Trust
System-wide access drives utilization
across the entire health ecosystem
A&E / Hospitals
Patient
Assessment / DST
GP’s
CFT / Social Care / Volunteer/ 3rd sector
Business Intelligence
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The Rotherham NHS
Foundation Trust
The Challenge: reduce time wasted on
manual communication / paper process
The Rotherham NHS
Foundation Trust
The Solution: a common referral & automated
process to direct clinicians to appropriate services
The Rotherham NHS
Foundation Trust
Assessments ‘waiting for completion’
More than halved
DTOC reduced 23% overall, driven by 63%
across ‘waiting for completion’
The Rotherham NHS
Foundation Trust
The Rotherham NHS
Foundation Trust
But even more so:
collaboration of
teams,
resulting in outcomes
we can ALL be very
proud of!
The Rotherham NHS
Foundation Trust
Across the Commonwealth, dramatic
results in reduced DTOC!
Over the last 4-year ends, patients waiting
in hospital beds for more appropriate care
levels/locations has trended down to a low
of 27 clients over 2000 beds!
ALOC days are now <2% of total acute beds
-Nancy Hughes, Director CHR
The Rotherham NHS
Foundation Trust
Gains maintained over the years
The Rotherham NHS
Foundation Trust
Patient choice & satisfaction increased!
• A demonstrable increase from 60% to 84% of
first placements to a location / geography of
patient choice!*
*Auditor General Alberta
Calgary Annual Report 2002/2003
The Rotherham NHS
Foundation Trust
The Rotherham NHS
Foundation Trust
International Reference: Internal Strategy
Internal Strategy / Training Video
RM&R today – z patient & family’s perspective
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The Rotherham NHS
Foundation Trust

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