Maggie Kemmner discusses how the Lambeth and Southwark Integrated Care Programme has been helping to improve the care of older people in the area.

1. An area-based approach to designing effective person-
centred services
Maggie Kemmner
Lambeth & Southwark Integrated Care Programme
Social care
Social care
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2. Lambeth & Southwark partners
Our partnership includes:
• Two acute & community healthcare providers
• Mental health provider
• Social care in two boroughs
• Up to 99 GP practices
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3. Our approach combines pathway and system design
Redesigned A new system
services and IT & where we all
care pathways informatics think and work
Holistic together
care: differently
How & what
organisations
Older are paid
people
Governance across Our goals:
Long-term participating
conditions organisations • Healthier and more
in working-age independent people
adults Workforce & • People have a better,
change in coordinated experience
practice
• Increased value for our
spend on local health and
social care
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4. Older people in Lambeth and Southwark – current picture
23600 have a limiting long-term illness
29000 annual ED attendances (KCH and STT)
330 people attend ED >4 times a year 8900 need help with mobility
…of which 56 are hardly ever admitted 1040 receive intensive home
…of which 55 are almost always admitted 12800 fall each year care
18500 annual emergency admissions 1055 live in care homes
…of which 3500 discharged on the
same day
50000 6000 a year referred to
…of which 1420 last over 30 days
People district nursing,
600 to community matrons
92000 annual outpatient attendances (incl 7000 85+,
…and 1970 people attend at least monthly 14500 BME) 17700 live alone
28000 live in social housing
170 admissions to MHOA/SLaM beds
1300 people on CMHT caseload 8% of GP lists 3400 care for others
(Ranging 3-18%)
Approx 5% unregistered?
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5. Holistic integrated care for older people
– not a disease-based approach for two reasons…
- Reality of people’s experience:
Over 50% of people in Scotland
aged 65+ have more than one LTC
(Mercer et al 2011)
- Enables coordinated focus on greatest
needs and risks, improved experience
- Local people said we had to!
Need sufficient impact to close beds and
shift funding
…With a great A meaningful group to all partners;
byproduct: cross-sector data availability
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6. A whole population approach, to identify risks early;
with interventions tailored to levels of risk and individual need, to prevent
deterioration in individual cases
50,000
older 25,000 Generic
people: proactively assessed 5,000 case managed approach based
All risk annually on level of risk
stratified
Prioritises action Picks up issues for Coordination of
for those those not yet care for those with
interacting heavily interacting heavily multiple needs
with the system with the system
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7. Also need to provide the right tailored interventions,
to prevent deterioration for individuals
We reviewed the last 3 years’ emergency admissions
All emergency bed-days* at GSTT
and KCH, Apr 08- Mar 11 (Age 65+)
12%
21% Long term conditions
Infections To identify avoidable admissions
19% Trauma & falls with senility
Cardiovascular events To prioritise conditions where we
needed to have impact
18% Cancer
7% Other specified To work out whether proactive
interventions or an alternative acute
Other not classified
10% 13%
response could help
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8. Need to respond to what people are being admitted to hospital for…
Treatment can be delivered Treatment can be delivered Treatment/diagnosis requires a
in ambulatory/home settings in ambulatory/home settings hospital procedure
Long term condition,
deterioration well
understood/predictable
Acute onset,
unpredictable, no
previous symptoms
More likely that planned More likely that only rapid Less likely that planned OR
and/or rapid community community interventions rapid community interventions
interventions will help will help will help
Eg Infections
% people
% of admitted who % less
people don't have a activity at % of these
Annual Annual dying in hospital weekend admissions
Condition admissions bed-days hospital procedure* s that are ACS**
Respiratory Influenza, Pneumonia 508 6940 25% 72% 13% 56%
Other 233 2398 15% 73% 6% 43%
Urinary tract 593 9003 6% 76% 21% 42%
Skin mostly cellulitis, some non-chron 140 1713 4% 71% 40% 33%
Septicaemia (blood infections leading to whole-body i 68 1163 45% 68% 14% n/a
gastro-intestinal 56 889 9% 80% -17% 28%
Grand Total 1596 22106 15% 74% 16% 43%
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9. A whole population approach, to identify risks early;
with interventions tailored to levels of risk and individual need
Specific tailored interventions on falls, dementia,
nutrition and infection pathways
50,000
Older 25,000 Generic
People: proactively assessed 5,000 case managed approach based
All risk annually on level of risk
stratified
Prioritises action Picks up issues for Coordination of
for those those not yet care for those with
interacting heavily interacting heavily multiple needs
with the system with the system
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10. Wave 1: Older People target impact, year 3, against baseline
(Emergency) Activity for all people aged 65+
Acute care Impact Social care Impact
Admission avoidance: Long term care package
Overall impact on bed days, % 9.7% reductions:
Reductions in nursing home 0 beds
Overall impact on bed days, # 10,752
caseload (would expect some
Equivalent number of freed up beds ~29 impact but too difficult to model)
(assuming 100% occupancy) Reductions in residential caseload 30 beds
Length of stay reduction:
NET reduction in domiciliary care 114 packages
Overall impact on bed days % 4.7% caseload
Overall impact on bed days # 5,170
Equivalent number of freed up beds ~14
Total:
Overall impact on bed days, % 14.4%
Freed beds across GSTT and KCH: ~44
Note: Length of stay savings are net after all avoided admissions, i.e., no double counting
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11. Better prevention… Advice & Better urgent
increased
investment in
response… Rapid
response
People with preventative People who team and
specific interventions don’t need HomeWard
risks * specialist acute nursing
assessment
HALF are
Support for People who can
All assessed People stay at home
older annually to People needing urgent
Expansion in response in
people identify risks social care
proactively in acute general
aged reablement crisis practice Better
65+ People
geriatrician
access:
needing
phoneline and
ALL are specialist &
bookable hot
regularly risk- MDT input
Higher clinic alongside
stratified A&E
based on risk
patients People who
level of past present at
service 10% are A&E People who are
interaction case admitted
managed
(in primary
care and by
community simplified
matrons), discharge
supported by process
CMDT
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12. Where next?
• Expansion of CMDTs to 100% coverage by Jan 2013 (currently at 50%)
• Supporting implementation and starting learning cycles
(introducing our Value-based reporting system and formative evaluation)
• Developing a holistic approach to working age adults with LTCs
• Virtual patient record procurement
• Work to develop a capitated budget
Thank you!
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