Windsor & Maidenhead Integrated Primary Care Team
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- Evelyn Willis
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1 Windsor & Maidenhead Integrated Primary Care Team
2 Meeting the LTC challenge through IPCT GP Older Peoples Mental Health Team District Nurse Practice Nurse Comm. Matron Care Coordinator Social Worker
3 The Integrated Primary Care Model Identify Service User ACG tool used to identify patients most at risk or requiring acute care episodes. Clinical judgement used to supplement the risk stratification tool. Integrated care Meeting Monthly meetings lasting 1 hour Core team attend New patients presented & existing patients reviewed Lead/key worker nominated Review / discharge agreed Care Plan Multidisciplinary team discuss patient Team agree action plan :-- - plan of care - multi agency escalation admission avoidance plan Self Management Care plan is developed with the patient and emergency interventions agreed and shared Onward Referral Patient referred to supporting services in the community Ongoing Care Patient remains on IPCT whilst at risk Patient on caseload of key professional if deemed beneficial Care Plan Review IPCT team : Review plans of care & progress Implement further actions to manage the patient in the community, including onward referral as necessary Agree follow-up period. Care Delivery Appropriate professional s undertake assessment of the patients needs IPCT members provide patient with the necessary care to prevent admission. Lead professional agrees and educates patient regarding care plan or multi agency escalation admission avoidance plan
4 W&M IPCT progress Monthly IPCT meetings All practices participating by August new patients discussed at IPCT 79 patients with Multi agency admission avoidance escalation plans/ self management plans 87 discharged patients Successes evidenced through case studies & ACG data up until June13
5 Case study: Mr C (Lead Professionals: Carron Edgell, RBWM & Parkinson's Specialist Nurse) 3 LTC -Parkinsons, Hypertension, Osteoporosis Pre IPCT High cost user: 41 GP appointments, 5 A&E attendance including admission in 1 year Concern regarding appropriate care package Patient felt not coping at home Post IPCT Outcomes (Feb 2013) GP visits since referral = 4 (2 for acute problems, and 2 routine management) Reduced A&E attendance (1 in 8 months) Escalation plan - medication advice & carers advice on deterioration in mobility or confusion Supported housing offered, additional care visit including emotional support
6 Case Study: Miss B (Lead Professional: Anya Ryan, Community Matron) 2 LTC Epilepsy and Chronic Pain Syndrome. Pre IPCT Bedbound 23 hours/ day most days Socially isolated 16 GP visits in one year High risk of developing other problems & cost Post IPCT outcomes (Feb 13) Social inclusion: SportAble weekly art classes Cost reduction over last 12 months 2, Patient feedback: CM is always really positive, proactive and acts on her word without hesitation. I can trust her and value her input and look forward to her visits Significant reduction in GP visits - 6 since Feb 13
7 Miss B trend analysis
8 Case study: Mrs L (Lead Professional: Ann Summers, Community Matron) 8 LTC- DM, OA, Dementia, AF, LVF, CKD stage 3, Hypertension, CVD Pre IPCT 7 hospital admissions in 1 year. Home 8 days over 3 month period. Frequent GP & CM visits Post IPCT Outcomes (Feb 2013) Improved quality of life No hospital admissions Fewer GP & CM home visits Escalation Plan: Rescue antibiotics for UTI Short term support : hourly fluid intake between carer`s visit while symptomatic Home treatment team for support when agitation and delirium
9 Case study: Mr M (Lead Professional: Alison Gemmel, Community Matron) 3 LTC- COPD, Prostate cancer and osteoporosis Lives with wife with multiple co-morbidities and complex family social issues Pre IPCT Mobility variable due to chest condition 9 GP appointments in 1 year Risk of admission due to chest condition High level of anxiety and stress due to family dynamics Post IPCT Increased understanding of LTC Improved Compliance with medication Self management plan-for chest condition including rescue medication Exercise tolerance increased, attending SMILE course Support for family regarding family social issues leading to reduced anxiety for all family members Reduction in GP appointments, 2 since June 2013
10 Questions/ Feedback How can we make IPCT work?
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