Download - Jonathan Higman, Director of Strategic Development, Yeovil District Hospital NHS Foundation Trust
SYMPHONYPERSON-CENTRED, CO-ORDINATED CARE
SYMPHONYPERSON-CENTRED, CO-ORDINATED CARE
A Journey to Improve the Care of People with Long Term Conditions in South Somerset
Jonathan Higman, Yeovil District Hospital
27 October 2015
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Introduction
Demographic changes are driving up costs in the local health economy and across the NHS
• More people, with more complex needs, require our care, support and treatment
• Demand during winters is increasingly unsustainable for providers – we are experiencing pressure now akin to winter pressures five years ago
Providing sustainable services is becoming increasingly difficult
• Financial challenges are being experienced across the NHS and within social care
• Recruitment and retention is increasingly difficult for care providers
There is a national drive for innovation on the frontlines of the NHS
• NHS England are looking to the frontlines of the NHS to provide the solutions to these challenges
• Replicable, new local models of care will influence and inform the structure of the health service across the entire country.
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Demographic change Proportion of the population aged 65+ by LSOA - 2023
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Demographic changeProportion of the population aged 65+ by LSOA - 2033
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Relationship between age and number of long term conditions
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Pat
ien
ts (
%)
Age band (Years)
Morbidity (number of ETGs) by age band
0
1
2
3
4
5
6
7+
Number ofconditions
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Relationship between number of long term conditions and cost
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Asthma - Relationship between number of long term conditions, cost and care setting
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Population segments Cost breakdown
Complex patients with many conditionsHigh Cost (over £7k/yr)
Less complex patientswith fewer conditionsModerate cost (£1-7k/yr)
Mainly healthy patientsLow cost (under £1k/yr)
Population cost pyramid, South Somerset
78%~90k
18%~20k
4%~5k
~15%~£20m
~35%~£55m
~50%~£75m
From patient to population
Source: South Somerset Symphony project data 12/13, Oliver Wyman analysis
Note: 1 Community service activity (e.g. district nursing) data not allocated to individual patients, therefore not included here
~£150m total cost; Primary, secondary, community1, mental health and social care
The top 4% of population drive 50% of the cost; the top 22% drive 85% of the cost
Potential local solution
Patient-centred, holistic coordinated care→ Symphony / ExtensivistComplex Care Hubs
Proactive chronic condition management→ Enhanced Primary Care
Efficient primary care, proactive health and well-being services
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Extensivist care modelThe patient is assigned a care coordinator and offered more care, support and attention through a number of services
Complex, Poly-chronic Patients
Key Worker
Expert Generalist
Extended Care Team
Therapies e.g. Physio
Mental Health
Social Care
• Diabetes• Respiratory• CHF• Dementia• Other…
Network of Services
Care HomeAcute CareAdvanced
Diagnostics
Core Care Team Key Elements
Comprehensive assessment of physical, mental health and social care needs
Support and coaching for patients and carers
Co-ordination of integratedpathway
Routine contact and monitoring of patient’s health and care needs
Proactive development of personalised health and social care escalation plans
Rapid crisis responseOther services…
Care Programmes
Care Coordinator
GP
FOPAS (Crisis
Support)
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Enhanced primary care modelThe patient and key worker are supported by the wider care team and a number of care programmes and services
Patient with Chronic Condition
Key Worker / Health Coach
GP
Care Programmes
and Specialists
Other programmes…
Extended Care Team
Therapies e.g. Physio
Mental Health
Social Care
CHF
Respiratory
Diabetes
Dementia
Network of Services
Care HomeAcute CareAdvanced
Diagnostics
Inte
rfa
ceCore Care Team Key Elements
Team Working and Huddle
Triage
Stratification and Proactive Outreach
Care Planning and Coordination
Defined Workflows and Programme Integration
Aligned Resources and Incentives
Shared Clinical Data and Population Health Analytics
Practice Nurse
Other services…
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Meet the Symphony Hub Team
Extensivist – GP or hospital doctor with interest in integrated care and Extensivist
role
Liaising with other health professionals including patient’s own GP and hospital specialists regarding care plan and any
proposed treatment plans
Care Coordinators - clinically trained as nurses or therapists
Liaises with family, carers, other health and care staff involved in care for
development of definitive care plan
Keyworkers – empathetic people with previous experience working
in health or care
Works alongside patient and family through care planning process
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Patient
Carer
Keyworker
Care-Coordinator
Extensivist
GP
Selects patient and refers them into the hub
Symphony HubPatient Journey
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Referral leaflet
• Complex patients with 3 or more long term conditions, and high hospital activity
• Patients with most complex conditions (such as diabetes, COPD, and cardiac problems) require more help
• GP selects suitable patients and complete referral leaflet..
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Patient
Carer
Keyworker
Care-Coordinator
Extensivist
GP
Selects patient and refers them into the hub
The Hub receives the
referral
Symphony HubPatient Journey
Contacts patient with leaflet and
Consent form
Happy to consent
If have Carer, also consent
Single point of contactWith Symphony Care
team
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Patient
Carer
Keyworker
Care-Coordinator
Extensivist
GP
Selects patient and refers them into the hub
The Hub receives the
referral
Symphony HubPatient Journey
Contacts patient with leaflet and
Consent form
Happy to consent
If have Carer, also consent
Single point of contactWith Symphony Care
team
16SYMPHONY | PERSON-CENTRED, CO-ORDINATED CARE
Patient
Carer
Keyworker
Care-Coordinator
Extensivist
GP
Selects patient and refers them into the hub
The Hub receives the
referral
Symphony HubPatient Journey
Contacts patient with leaflet and
Consent form
Happy to consent
Visits patient at home, and
develop Care Plan
If have Carer, also consent
The process begins…
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Patient knows best
• Patient centred goals
• Escalation plan
• Holistic, not just medical
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What issues I would like to talk about today to help improve my health and lifestyle
Finances Housing Medication
My mood
Meeting other
people
Understanding
my condition
Transport
Physical
Activity
Hobbies and
Pastimes
Caring for
others
Time
management
Weight
Management
Smoking
Sleep
Food
Being able to
plan my life
Work
Memory
Religion
/beliefs
Relationships
Pets
Test
Results
Coping at
home
Eyesight
Hearing
Care Plan
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First Visit
• Referred by GP
• Most of the visit was taken up listening
– Others had not had time to listen
– Confusion about what other services could offer which impacted on his engagement
– “Abandoned”
– Only service that has listened to what he had to say
• Could not read or write, not previously disclosed and effected his confidence
• Also suffered from agoraphobia and bipolar
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Second visit
• Visit from Extensivist and Care Coordinator
– Modified medication and liaised with GP
• Pending surgery
– Had decided not to have it “nature would take its course”
– This changed when he spoke of his family
• Agreed a support plan
– Use of ipad to download films as distraction
– Support from Care Coordinator to go with him
– Coordination of appointments on one day by team
Pre-assessment appointment
• Was out of the house for 5 hours which he had not done for 7 years, this built his confidence
• Redefined his goals to include giving up smoking and visiting a garden centre
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Outcomes
• Surgery was successfully completed at Musgrove Park Hospital, Taunton in August
• Care Coordinator was able to support him before the surgery, and interacted with the hospital team so his mental health effects would be kept to a minimum
– Able to be discharged early
– Symphony team provided daily support
– Still in recovery
• Smoking reduced from 40+ to 7 per day
• Going out in his garden more and has been out to the shop
" I couldn't have done this without Symphony, there must be hundreds of patients like me Symphony could be helping out
there"
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Symphony Complex Care Hub – Initial Outcomes
Hub Patient Outcomes – Number of EventsApril to August 2014 vs. April to August 2015
Hub Patient Outcomes – Average Length of StayApril to August 2014 vs. April to August 2015
3130
2220
20
25
30
195
0
15
200
5
10
OP Appointments
197199
A&E AttendancesEmergency Admissions
14
0
10
7
00
5
7
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Emergency Community
Elective Community
Emergency Acute
Elective Acute
Before (April to August 2014)After (April to August 2015)
Nu
mb
er o
f Ev
ents
Ave
rage
LO
S (d
ays)
-33% -29% -1% 0% -46% -100%Source: Data collected as part of LIG evaluation – data for April to August 2014 (before) and April to August 2015 (after)
0%