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

1SYMPHONY | PERSON-CENTRED, CO-ORDINATED CARE

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.


Demographic change Proportion of the population aged 65+ by LSOA - 2023


Demographic changeProportion of the population aged 65+ by LSOA - 2033


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


Relationship between number of long term conditions and cost


Asthma - Relationship between number of long term conditions, cost and care setting


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


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)


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…


Meet the Symphony Hub Team


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


Patient

Carer

Keyworker

Care-Coordinator

Extensivist

GP

Selects patient and refers them into the hub

Symphony HubPatient Journey


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..


Patient

Carer

Keyworker

Care-Coordinator

Extensivist

GP


The Hub receives the

referral


Contacts patient with leaflet and

Consent form

Happy to consent

If have Carer, also consent

Single point of contactWith Symphony Care

team


Patient

Carer

Keyworker

Care-Coordinator

Extensivist

GP



referral



Consent form

Happy to consent


Single point of contactWith Symphony Care

team


Patient

Carer

Keyworker

Care-Coordinator

Extensivist

GP



referral



Consent form

Happy to consent

Visits patient at home, and

develop Care Plan


The process begins…


Patient knows best

• Patient centred goals

• Escalation plan

• Holistic, not just medical


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


Patient story


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


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


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"


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%


SYMPHONYPerson-Centred, Co-ordinated Care

Healthcare

Jonathan Higman, Director of Strategic Development, Yeovil District Hospital NHS Foundation Trust