s109 – day 1 – 1315 – achieving patient orchestrated care

Patient Orchestrated Care

Bridget Fletcher, Chief ExecutiveDr Richard Pope, Hon Consultant Physician

overwhelming need for

change

“Trabant Care”

“…I am scared to say something in case there are consequences…”

Through their eyes…

“…I know you are busy but I am important too…”“…Make me feel I matter…”

“…I am not a disease – I am a person…”“…This may be routine for you – but for me it

is the first time…”

“…I may be old – but I have a brain…”“…Different professionals are telling me different things – who is right?...”

““Apple Care”

Incremental vs Disruptive Innovation

“Our NHS does a superb job

for millions of people, day in, day out,

but it cannot stand still

– it needs to adapt to survive”Sir Bruce Keogh

Traditionally….

Potentially…..

How can a person orchestrate their own care?

Teleconsultation - Airedale 8 year journey Initially prison healthcare Today work with prisons

across England ~ 800 cases/year Wide range of specialties Have extended services……

Current applications

Telehealth Hub 24/7 working Experienced nurses 2nd tier - physician Range of technologies Shared EHR Resilient infrastructure Opened September 2011

Nursing & Residential Care homes

n=96 live today deploying to 190 Cumbria to Kent

Care home caseload audit (Feb 2014)

Current care homes Mix of Residential /

Nursing Total 2500 residents Aged 26-106 Looking only at those

homes that refer into Airedale hospital ….

Call outcomes

Care Homes - summary

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700Acute Admissions 1Year Prior toDeployment ofTelemedicine

Acute Admissions 1Year PostDeployment ofTelemedicine

-35%

Care Homes continued

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1000A&E Attendances 1Year Prior toDeployment ofTelemedicine

A&E Attendances 1Year PostDeployment ofTelemedicine

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10000Acute Beds Days 1Year Prior toDeployment ofTelemedicine

Acute Beds Days 1Year Post toDeployment ofTelemedicine

-53%

-59%

Results: 24 hr teleconsults to 26 COPD patients at home – 1 year pre/post

-45%

ED attends-60%

Feedback…

“I would like to express my gratitude and thanks for the

level of care you have provided my husband, in

particular the consultation at the weekend – the service is

marvellous.”

“The Doctor was fantastic when one of our dementia patients fell and hurt

herself. I would have called an ambulance and she would have endured an A&E visit which would have terrified her. Your consultant saved her from this

and reassured me that the cut was superficial and she was fine…”

“A very good service. It made me confident within my job so I could do the best I can for our residents. This service taken

the pressure off us as we have access quickly to a health

professional.”

“I have only one word to describe Telehealth –

excellent.”

“ The Telehealth Hub came into its own last winter when snow and ice brought traffic to a halt. My Husband’s condition deteriorated suddenly and having visual, instant contact with the team was very

reassuring. A wonderful service.

People want to “live” with their LTCs

The NHS needs increased Quality

and Improved EfficiencyThese seemingly conflicting demands can be resolved by

A different Patient Clinician

Engagementmaking it personal, not simply clinical

Scale - to thousands of HCPs, millions of Patients

People with LTCs - owning their plans and defining their support

First tried it ‘on paper’ – cohort of 50 carefully tracked

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Acute admissionsPre-care planning

Post care planning

Published in HSJ Dec 2010: “QIPP and Care Plans for long term conditions”

Example - engaging with own action plan

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1.00

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Exercise sessions per week

Starts using SSC here Patient generated data

Feeling better – motivated by results

12/23/11 0:00 2/11/12 0:00 4/1/12 0:00 5/21/12 0:00 7/10/12 0:00 8/29/12 0:00 10/18/12 0:00 12/7/12 0:00 1/26/13 0:00 3/17/13 0:00 5/6/13 0:0070.00

72.00

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82.00

Weight (kg)

Starts using SSC herePatient generated data

Clinician generated data

Achievement confirmed by clinical results

1/22/10 0:00 8/10/10 0:00 2/26/11 0:00 9/14/11 0:00 4/1/12 0:00 10/18/12 0:00 5/6/13 0:000

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Haemoglobin A1c level - IFCC standardised

Starts using SSC here

QoF

Clinician generated data

In control – aged 80 and happy!

In control,80 & happy

Initial Cohort - age profile

yrs

Patient No.

BP before and after 6 months use of supported self care

BP before and after 6 months use of supported self care

Patient No.

mm Hg

Ave reduction SBP=19mmDBP=13mm

HbA1c change over 6 months following introduction of supported self care

Ave = -16 mMol/Mol

Weight change (Kg) over 6 months following the introduction of supported self care

Ave loss = 4.5Kg

The person orchestrating their own care with clinicians working by exception

Technologies converge….

signalling choice & needs near the end of life

s109 – day 1 – 1315 – achieving patient orchestrated care

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