Q Exchange
Supercharging integrated care for long-term conditions across whole patient journey
- Winning idea
- 2024
Meet the team
Also:
- Prof P Cockwell - ICB LTC Clinical Lead & Renal Consultant
- Suzanne Clearly – Chief Officer Strategy Partnerships Community NHS Trust
- Dr. Adnan Nadir - Consultant Cardiologist UHB Trust
- Dr. Amar Putanna – Diabetes Consultant
- Dr. Matt Swallow - Respiratory expert
- Simone Wilson – Head of LTCs (Primary Care)
- Ramandeep Sandhu – Head of Pharmacy
- TBC – Expert patient
What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?
1 in 3 adults in the UK are living with a long-term conditions (LTCs), also defined as a non-communicable chronic disease. The current approach to managing service users, who have multiple LTCs, is usually based on traditional episodes of care where each condition is managed in isolation and reviewed separately, resulting in patients having avoidable additional appointments.
This disempowers the patient. Those at highest risk have multiple LTCs but are not supported to make decisions across LTCs that are based on their needs. This is an inefficient use of clinical resources with patients experiencing long waits on multiple specialist lists in secondary care and sub-optimal polypharmacy management plans. Despite shared pillars of care for many for circulatory diseases.
This also exacerbates health inequalities for patients from deprived communities, who find it difficult and costly to attend multiple appointments in hospital. We are pioneering cross sector collaboration to support those with multiple LTCs.
What does your project aim to achieve?
We will optimise care for patients with LTCs by working differently to support their care across the whole care delivery system. We know that multidisciplinary team working has proven success in single specialty initiatives, but they are later in the patient journey and for single conditions.
We will supercharge integrated care by combined working across multiple specialties. This will start from early in the development of disease by identification at a practice level. Patients will then be managed by integrated teams that combine expertise from primary care, community healthcare trusts and secondary care providers. This will have unique ability to create our first ever LTC specialist clinicians.
Patients will have fewer appointments and local easy to reach access, to reducing health inequalities. It will enable accurate use of disease modifying therapies where there is a known benefit and avoid potential harmful interactions that develop from having conditions managed in isolation.
How will the project be delivered?
Our pilot will enable clinicians working together from primary, community, secondary care and voluntary sector, on a single shared care record with full access to patient notes that already exists in primary care but whose potential has not been exploited for this joined up care approach. This ensures a much more efficient interface and communication between these clinicians from different sectors and organisations. This approach will also enable more rich and comprehensive care plans for patients with their whole medical history being available in detail to these clinicians.
This approach does not need the purchasing of new IT systems, instead it is a more sustainable and scalable approach of using existing resources in a different way that supports a new model of care.
We will utilise a comprehensive ‘lean sigma’ approach to develop clear and measurable project goals, maximise limited resources and continually improve using learning from each delivery sprint.
How is your project going to share learning?
The clinicians are from across the whole care delivery system helping to provide champions to promote this new way of working in all sectors. We will utilise patient experts to support co-design.
The use of a shared care plan, agreed with and reviewed by the patient, with cross-specialty support in system delivery will put the patient with LTCs at the centre of their care. The teams involved are working as senior faculty the BSol ICS, which has the most challenged socio-economic profile and structure. There is a commitment throughout ICS to develop this model such into the cross-organisation working that is being developed. This will provide learning and sharing opportunities to support patients and clinicians in the ICS.
We will share this work through local, regional, national platforms including open learning forums to support the development of the model. This offers a unique opportunity for individual and wider workforce development.
How you can contribute
- Would welcome ideas on how to ensure successful stakeholder engagement with such a complex areas of multiple specialties.
- Would welcome ideas from those with NHS commissioning expertise on the kind of data and impact they would be interested in seeing to influence change in commissioning intentions, to ensure sustainability of this new way of working.
Plan timeline
| 1 Jul 2024 | Hold first cross sector Clinical redesign workshops |
|---|---|
| 14 Jul 2024 | Agree collaborative ground rules for LTC MDTs and project |
| 1 Aug 2024 | Design searches to identify relevant LTC MDT patients |
| 7 Aug 2024 | Develop evaluation, user feedback and data collection processes |
| 18 Aug 2024 | Set-up and refine IT requirements |
| 28 Aug 2024 | Develop communication and engagement materials |
| 2 Sep 2024 | Stocktake review workshop to learn further lessons and refine work |
| 6 Sep 2024 | Launch first small scale test MDTs |
| 17 Sep 2024 | Refine LTC MDTs based on feedback and rollout more wider |
| 17 Oct 2024 | Collect Clinical, service user and staff feedback and impact data |
| 10 Dec 2024 | Share early learning of pilot |
| 9 Feb 2025 | Develop draft report of learning and sharing |
| 2 Mar 2025 | Share learning and findings locally and nationally including final report |
Comments
Sarah De Biase 15 Jul 2024
Mani, we are embarking on a similar journey in WY for those living with multiple long term conditions. I would really like time to discuss with you if you’d be willing to share your email?
I am at Sarah.debiase1@nhs.net
Bw
Sarah
Mani Dhesi 31 Jul 2024
Hi Sarah,
Thanks for reaching out and great to hear you are undertaking similar work.
Would be more than happy to arrange a catch up to share ideas and learning. My email is mani.dhesi1@nhs.net.
Thanks
Mani
Catherine Richards 6 Jun 2024
Hi Mani,
This sounds like a great initiative, have you considered how this approach may impact on environmental sustainability? as well as positive outcomes for patients/ populations and social and financial impact for patients and services. It would be great for this to be a consideration as your planning improvements and in measuring outcomes. The potential for this to reduce unnecessary appointments, reduce travel and reduce polypharmacy will all have positive environmental impacts.
look forward to hearing more!
Mani Dhesi 31 Jul 2024
Thanks Catherine for very helpful feedback and useful prompts, very good suggestions that I will discuss with team. With a need to prove impact this is a very valuable additional layer to consider of potential impact. Thank you for taking time out to comment.
Vincenta Leyden 29 May 2024
This is a great approach to providing care. The MND Association in Northern Ireland is working towards this collaborative approach. With the Southern Trust (SHSCT) we have invested funds to develop a clinical coordination role to replicate what you are aiming do - cross-specialty support in system delivery. We are at very early stages, but would like to hear the learning from your pilot. Have you engaged your QI team - or a team who might chart your progress/ learning for scale and scope at the end of your project. I would be interested to hear more. Thanks for sharing and good luck.
Mani Dhesi 30 May 2024
Thanks Vincenta for taking time to review our proposal and thanks for the support. Much appreciated. If successful we will definitely share more.
We are a small organisation, we do not have anything like a QI team but we do have a number of staff who as part of normal role have recently either added or asked to dust down previously used QI skills, to helps us as organisation to take a greater QI focus. To enable us to ensure more robustness in our change work, collect stronger impact data and support more spread both locally and wider.
Best wishes
Mani
Francesco Palma 23 May 2024
I like this proposal. Consider this: the King's Fund back in 2012 informs that 4 million people in Englandhas a long term physical health condition also has a mental health condition so in your intergrated care across the LTC's that you will engage with there will be a proportion of the patients that would benefit ( if unknown to services) advice, guidance & signposting to Talking Therapies to support those impacted by Anxiety & Depression.
Your Cardiometabolic Syndrome intergrated screening/testing I like, as a Cardiovasular patient that's experienced 3 MI's/Quad CABG/OHCA/HFrEF@30%(ICD Impacted) I feel that your proposal would have made a difference if available in my situation yearr ago.
With respect to Co-create/design/production of your intervention it would be useful to have your pitch updated to inform that you have a Lived experience patient although better still Lived Experienced Panel to all the Long Term Conditions that you have highlighted I will leave it here but would add more if time was available.
Mani Dhesi 30 May 2024
Thanks Francesco for taking time out to comment, sorry for delayed response been on leave!
Very helpful suggestions.
We currently work vary closely with our Mental Health local organisations and many of their staff work in an integrated way in our other services. Agree with your suggestion about adding this input/support to the pathway will be very helpful.
In terms of patients with lived experience, we had a meeting a few months ago at looking at enhancing our approach in this arena. We are looking to set up a comprehensive approach that not only collects input at a specialty level but also looks at how we can then layer that with more understanding and information of the experience of living with multiple long-term conditions. A crucial factor in ensuring what we deliver is fit for purpose.
Thanks again for helpful comments.
Best wishes
Mani
Lucy Cartwright 21 May 2024
This work really resonates, and I'm excited to see it progress. I'm working a in a system with a large elderly frail population, and the management of long term conditions closer to home is a core focus of our systems improvement coaching for united neighbourhood team work.
I'm interested in understanding, what are some of your ideas for managing flow through an MDT? Will you be considering specific conditions or the combined impact of any combination of conditions (measured through an outcome measure)?
Mani Dhesi 30 May 2024
Thanks Lucy for very helpful reply, sorry for delayed response been on leave!
At present there are 2 routes planned, if we are successful, for flow of patients. The first is direct from Primary Care for patients that have complex MDT patients that would benefit from being reviewed holistically. The second is from existing clinics that patients are currently reviewed/supported in isolation be that in Community or Secondary care e.g. Diabetes, Respiratory, CVD, Renal etc. The Clinicians in these traditional single speciality clinics will have a much needed route to have the patients be reviewed at this MDT holistic review clinic.
We will then look at collection of outcomes and impact on both the original isolated speciality they started journey on and overall impact on health of the identified additional areas the MDT recommends support with.
Thanks again for taking time to comment.
Best wishes
Mani
Paul Cockwell 19 Mar 2024
Thanks so much for the helpful comments both on line and from colleagues who have had the opportunity to review within the team and beyond. We are adjusting the proposal to reflect these comments.
We are developing a framework in BSol ICB/ICS to ensure that any programme of improvement is seen by and shared across the system and developments that work for the population that we serve are embedded in our system transformation programmes and our commissioning plans.
Astrid 14 Mar 2024
Great opportunity for a co-design approach with service users involved at the start. I also wonder whether it may be helpful to include Holistic Needs Assessments (usually involved in cancer care) but could possibly support centering the patient in this new collaborative way of working? Either way, seems a promising project!
Mani Dhesi 14 Mar 2024
Hi Astrid,
Thank your for helpful suggestions and insights. The idea of exploring Holistic Needs Assessments as a transfer of approach from other areas is really great suggestion, so big thanks for prompt and we will definitely explore. Especially, as putting the patient at the center of a cross organisation support mechanism, is exactly what we are aiming to do.
Suzanne Cleary 14 Mar 2024
Great proposal and being local I know you have a track record of delivering improvements for patients. Also good to see you are starting with sustainability in mind by evidencing the impact for patients and the wider system, hopefully to provide evidence to commissioners / system provider collaborative partners that this is effective and efficient.
Mani Dhesi 14 Mar 2024
Thanks Suzanne for support for this project and endorsement of our approach to pro-actively ensure we are thinking ahead about working with commissioners about what we need to ensure we sustain benefits of the changes we are looking to implement.
Charlie Keeney 1 Mar 2024
Impressive collaborative partnership assembled to progress this innovative integration approach that’s centred on improving the coordination of care for people with multiple conditions. Couldn’t be more timely. Great to see how seeking input to strengthen patient engagement and advice on evidencing impact for commissioners. Wish you every success!
Mani Dhesi 8 Mar 2024
Thank you Charlie for taking time to comment. We are lucky to have such amazing clinical and managerial support for this collaborative project across our whole integrated care system. We truly believe this approach can help address many of our patients challenges of wanting and needing more holistic care for their multiple long term conditions in a timely and reduced appointment manner.
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