Leo Lewis, Senior Fellow at the International Foundation for Integrated Care, draws on experience from the Carmarthenshire Chronic Conditions Demonstrator programme in Wales, to look at the key elements necessary to deliver effective services for people living with, or at risk of developing, chronic conditions.

1. How can we co-ordinate care from
the information perspective
Experience from Carmarthenshire Chronic
Conditions Demonstrator, Wales
Leo Lewis
Senior Fellow
International Foundation for Integrated Care

2. Health and social care has tended to
create a series of
simple, disconnected, linear systems
each designed to maximise one goal…

3. …and yet we have the
knowledge, technology and imperative
to formulate a sustainable way of
delivering services rather than
pursuing approaches that simply
mitigate negative impacts.

4. Building the
CCM Model
Predictive Risk
Tool
Telehealth and
Telecare
Generic CCM
support worker
Generic Care
Pathway
Core MDT
CCM Teams
Locality
GP
Clusters
Care Co-
ordinator
CCM Model – population based c50,000

5. Ecosystems are
complex, interconnected and
interdependent and designed
towards an optimised overall system

6. From information to understanding

7. CCM model and framework: role of
care co-ordination
• Identify, plan and co-ordinate services to meet
needs at each of the model’s four levels
• Liaise with patients, carers and service providers
from private, voluntary, statutory and
independent agencies
• Monitor patient progress and service delivery
across primary, secondary, community and social
care
• Co-ordinate primary care collaborative networks
and networked services
• Advise on the commissioning of chronic
conditions services

8. Confusion!
Views on the Care Co-ordinator role:
• The person who took the lead in ensuring the
Unified Assessment process was implemented for
service users – either health or social services
• Case Manager
• Care Management
• Community Chronic Disease Management
Specialist Nurse

9. Clarification
Analysis of Skills for Health competencies for care
co-ordination, care management and case
management:
• 154 competencies delineated into three
functional areas:
– Strategic co-ordination and planning at a population
level
– Clinical/social care co-ordination focused on delivery
of services to individuals
– Data and information competencies to support other
roles

10. Care Co-ordinator
became
Care Services Planning Co-ordinator

11. Based on mid year estimates 2008 population growth & 2008/09 QoF as a
% of the total registered population 2009
Planning: chronic condition prevalence
Projected Over 75 years QoF Events by disease 2009 to 2014 & 2019
Towy Taf Locality
622
408
2823
254
1110
1369
281
252
521
742
39
339
65
628
689
503
493
695
456
3155
284
1241
1530
314
282
582
829
44
379
73
702
770
562
551
812
533
3687
332
1450
1788
367
329
680
969
51
443
85
820
900
657
643
0
500
1000
1500
2000
2500
3000
3500
4000
AF
Asthma
BP
Cancer
CHD
CKD
COPD
Dementia
Depression
(diagnosis)
DM
Epilepsy
HF
MH
Obesity
Stroke/TIA
Thyroid
Population>75
/10
QoF Disease area
Numbersofpatients
2009Evts>75
2014 Evts>75
2019 Evts>75

12. Planning and co-ordination: service utilisation
Emergency medical admissions
EMAs by Chronic Disease; Carmarthenshire Residents
0
100
200
300
400
500
600
700
800
900
COPD HF Diabetes All Type 1 Type 2 Other Diabetes
Condition
Number
Calendar Year 2004
Calendar Year 2005
FY 06/07
FY 07/08

13. Planning – population and individual:
predictive risk tool

14. Locality workforce profile

15. Individual care co-ordination: care plan

16. Planning and care delivery: health and social
care directory of services

17. Information to support others: multi-
disciplinary team meetings

18. Planning and delivery: chronic conditions
generic care pathway

19. Chronic conditions – average length of stay:
measuring achievement
F
eb
-0
8
D
e
c-0
7
O
ct-0
7
A
ug
-0
7
Jun
-0
7
A
p
r-0
7
F
eb
-0
7
D
e
c-0
6
O
ct-0
6
A
ug
-0
6
Jun
-0
6
A
p
r-0
6
10
9
8
7
6
Month
Days
_
X=6.817
UCL=7.446
LCL=6.188
1
6
5
5
1
Rolling 12 Months' Average Length of Stay
COPD Emergency Admissions
I Chart of Carmarthenshire by Month
Fe
b
-0
8
D
e
c-0
7
O
ct-0
7
A
u
g
-0
7
Ju
n
-0
7
A
p
r-0
7
Fe
b
-0
7
D
e
c-0
6
O
ct-0
6
A
u
g
-0
6
Ju
n
-0
6
A
p
r-0
6
5.75
5.50
5.25
5.00
4.75
4.50
Month
Days
_
X=4.813
UCL=4.971
LCL=4.656
Rolling 12 Months' Average Length of Stay
CHD Emergency Admissions
I Chart of Carmarthenshire by Month
Source: HSW Web Indicators SaFF 10
(Target 5.7 days)(Target 5.7 days)

20. From information to understanding:
our integrated community services care model

21. Care Services Directory Menu
Carmarthenshire Community Services Care Model
Identify Cases Initiate Care Process Care Delivery and ReviewCare Assessment and Planning
Information Point
for
Citizen, Carer, and
Professional
Single Point of Access
24/7
Response
Unplanned
Referral
Initial
Referral
Generate
Intervention
Requests
Diagnostic
Intervention
Assess
Planned
Community
Services
Intervention
Urgent
Community
Services
Intervention
Review
and Assess
Case
Finding
Self
Referral
Allocate
Key Worker
Enter
Referral
Unplanned
Community
Services
Intervention
Unplanned
Intervention
– (not CS)
Re-allocate
Prism and
PARR++
GP
Registers
Case Lists
Activity
Reports
Assessment
& Prioritise
Update
H&SC
Records
Update
H&SC
Records
Update
H&SC
Records
Escalate to Community
MDT Team Escalate
Main CCM Delivery Providers include:
Social Care, District
Nursing, Canllaw, DRT, CDM, General
Practices, Out of Hours, Ambulance
Trust, Voluntary Sector, Independent
Sector, ART , TC/TH
Integrated Health and Social Care Register
Discharge
Community
MDT Team
Update
H&SC
Records
Produce
Care Plan
Planned
Intervention
– (Not CS)
Normal
Unplanned
Info
Resource
Normal Path
Unexpected
Path

22. Integrated, comprehensive solution that addresses
multiple challenges simultaneously and coherently.

23. Rhayader Home Support Service

24. You never change things by fighting the existing
reality. To change something, build a new
model that makes the existing model obsolete.
Michael Pawlyn 2013