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Integrated Care

Scaling Up the Intermediate Care Pilots for Sustainable Change

Since July 2011 community staff from across health and social care have been working together to improve outcomes for patients by transforming intermediate care. Our 5 year vision for Adult Community Services is that all patients who do not require inpatient care will receive quality care outside hospital. This vision is based on achieving year-on-year savings that can be reinvested to further develop our services in the community. To achieve this vision:

  • Integrated teams will deliver pathways of care for chronic disease management.
  • There will be an urgent community response to health and social care needs 24 hours a day.
  • There will be a range of options for the provision of high quality end of life care which support individual choice
  • All inpatients will leave hospital fully informed with ongoing care plans once their hospital care is complete.

In year one the following new care pathways were piloted as a first step towards this vision:

Chronic obstructive pulmonary disease (COPD)

An integrated community care pathway was developed and piloted in one GP practice to provide care for patients exacerbating from COPD. The pathway was led by Central Manchester Active Case Management service in collaboration with the COPD Team and the GP practice. As part of the pilot the patients most at risk of exacerbation were identified, joint management and assessment documentation was used to create individualised multi-disciplinary care plans and an integrated end to end pathway for managing exacerbations in the community was agreed. Tele-health units have been installed for suitable patients and work is continuing to evaluate their use as a self management tool.

In the four months since launching the pilot, 12 patients were assessed as high risk and given an individualised management plan. Of these nine exacerbations were managed in the community without triggering a hospital admission and there were four hospital admissions which were deemed appropriate by the multi-disciplinary team. This represents a significant reduction for this high need GP practice in the busiest period of the year.

Funding has now been secured to upscale this pilot to all GP practices in West Gorton and Levenshulme; 40% of Central Manchester patients with COPD live in this locality.

End Of life

In order to increase knowledge of end of life care amongst residential home staff, a training package has been developed and delivered in three nursing homes by the district nurses. We are continuing to work closely with the residential home staff to increase the number of end of life care plans in the homes and the number of residents who die in their preferred place of care.

Since delivering the training, seven patients have died; six of these were able to die in their preferred place of care within the homes. Both of these residents had an end of life care plan in place and were cared for by the carers and district nurses in their preferred place of care.

Funding has now been secured to increase the district nursing service to a 24 hour service and roll out this training and support package to all residential homes in Central Manchester.

Falls

An Intermediate Care Assessment team has been developed to provide assessments to patients who fall in the community but do not require treatment in hospital. The majority of referrals are currently received by North West Ambulance Service but the community alarms service, district nurses, active case managers, A&E and the rapid response team can also refer.

Since January 2012 63 patients have been assessed in their own homes and 25 have been admitted onto the home care pathway for ongoing treatment and intervention.

Funding has now been secured to continue this pilot and to develop urgent response pathways for other medical conditions.

Continuing Health Care

An alternative system for Continuing Health Care assessments at the MRI was piloted aimed at making the process more patient centred.  A dedicated team including a health care worker and a social care worker was put together to guide the patient through the process from end to end.  Results have shown a reduction in the time taken from the beginning to the end of the assessment process from 38 to 19.5 days.

This has now been funded and will commence once recruitment is in place.