Long Terms Conditions Integrated Change Programme

1
Long Terms Conditions Integrated Change Programme

• Florence Cantle
• Assistant Director Long Term Conditions
• Croydon Primary Care Trust

2
Case Study

• James, 86 year old
• COPD, diabetes, arthritis
• 20 admissions in 2005/06
• 10 OPD appointments
• 30 GP appointments
• Not known to community nursing services
• Care worker twice a week for personal care and
  shopping
• No family feels abandoned by NHS
• Total estimated cost to the NHS 25,000 2005/06

3
SOLUTIONS

• Proactive case management assessment, care
  planning and co-ordinating the care in a
  multi-disciplinary setting
• Medicine review management
• Health promotion COPD, Diabetes
• Setting parameters to target interventions as
  early as possible e.g. ongoing dialogue with GPs,
  liaising with community nursing team, telephone
  contacts, home visits

4
THE VIRTUAL COMMUNITY WARD

• Virtual team led by community matron
• Risk stratification from Kings Fund algorithm
• Ward rounds daily, weekly and monthly
• Specialist input
• Ward clerk administrative tasks
• Monitoring progress
• Discharge planning

5
ISSUES/PROBLEMS

• Joined up approach with social care in terms of
  social care package
• Length of stay in the hospital - too long
• Facilitation of early discharge
• Communication with GP, pharmacy and Out of Hours
  service

6
BENEFITS OF THE INTERVENTIONS

• Improved quality of care provision
• Improved patients well being a holistic
  approach
• Avoided 3 hospital admissions in 2006/07
  amounting to 7,000
• Number of GPs consultation reduced by 50
• Number of Outpatient attendances reduced by 30
• Unfortunately, James died in January 2007

7
Any Questions?

• CONTACT DETAILS
• Florence Cantle
• Assistant Director Long Term Conditions
• 020 8274 6247
• Florence.Cantle_at_croydonpct.nhs.uk