Birmingham OwnHealth Investing for Health Delivering our clinical vision for a world class health se

1
Birmingham OwnHealth Investing for
HealthDelivering our clinical vision for a world
class health service
Dr Richard Mendelsohn - GP / Director of Chronic
Disease systems BEN PCT Anthony Nicholls
- Regional Business Development Manager
NHS Direct Adrian Reedman - UK Project
Manager Pfizer Health Solutions
2
The quote

• Chronic care in the future should largely be
  about a practitioner a phone and a computer
  rather than a doctor with a patient in a room
• SHA visit to The Veterans Healthcare
  Administration, Minneapolis 2008

3
Self-care for long term conditions Empowering
individuals to make positive health behavior
changes
4
What drives us

• PCT Core Purpose - working in partnership to
  tackle inequalities and improve health and well
  being
• PCT Goals
• To be so responsive to the population we serve
  that no one waits for the quality care they need
• That the health and well being of the population
  will have improved so much that people will enjoy
  10 more years of healthy life
• That people regard us as the first choice
  organisation to work with and for
• Our communities will the most involved, informed
  and empowered in the country

5
The vision

• A paradigm shift in personalised care would
  mean a service that
• can deal with lives not illness
• can move from paternalism to shared
  responsibility
• starts from where a person is, not where we
  think they should be
• makes the right thing easy to do for everybody
• adds value and continually learns to do better

6
The myths

• Its just a good nurse on the phone, we can do
  that in our practice
• We already do that, weve got a good PN/CaseM
  service that do that all the time and do a
  physical review of the patient every 6 months
• We are a high scoring QoF area, we would have so
  few patients that would benefit
• Lets redesign everything and make it into 1
  complete service
• Clinical accountability for the patient will
  change
• Shared care already works
• This could be the answer to all of our LTC
  management

7
What are the key determinants of health?
8
Creating a partnership to bring the skills
together

• Birmingham East and North PCT is responsible for
  commissioning and provision of health services
  for a diversely diverse population of 438,000.
  Geographically it covers 17 wards along the
  eastern half of Birmingham.
• Pfizer Health Solutions is a group within Pfizer
  Limited that operates independently of the
  medicines business and delivers disease
  management solutions in partnership with
  healthcare providers.
• NHS Direct is a multi-channel service which
  providesadvice and information about health,
  illness and health services to help patients make
  better decisions about their health and that of
  their families.

9
The partnership
10
What is the outcomes model based on ?
11
The Care Managers

• Take a holistic not just disease-based approach
• Are highly experience nurses
• Work with individuals to create a bespoke
  self-care plan
• Will call at agreed times, but will also take
  calls from individuals if necessary
• Build on the professional care provided by the
  primary care team
• Meet the GP practice team on a regular basis to
  share an individuals results
• Are supported by software that incorporates local
  pathways and guidance

12
Giving tailored support in eight specific areas
of care

• Knowing how and when to get help
• Learning about their condition and setting goals
• Taking medicines correctly
• Getting recommended tests and services
• Acting to keep their condition(s) well controlled
• Making lifestyle changes and reducing risks
• Building on strengths to overcome obstacles
• Following-up with specialists and appointments

13
The positive outcomes

• Individuals and their health behaviours
• eg Improved diet including decreases in fat and
  salt intake
• Increased exercise participation
• Positive changes in smoking habits

Clinical outcomes eg Reduction in HBA1c in
patients with diabetes Reduction in systolic
and diastolic BP
Service use rate changes eg Reduction in
appointments with GPs Fewer reported AE
visits Fewer reported hospitalisations
14
What next ?

• Offer the Service to all those who might benefit
  in the BEN PCT area
• Continue to deliver and further develop services
  for Walsall PCT, South Birmingham PCT and Heart
  of Birmingham tPCT
• Innovate, use the lessons we have learnt in our
  growth
• Data management
• Practice engagement
• Step up / down Care
• Obesity / Weight loss support
• Assistive technologies

15
The next 3 years

• Commissioned until 2011 to reach up to 27,000
  members
• To provide OwnHealth to individuals across BEN
  PCT
• To develop a new OwnHealth service thatbegins
  to integrate health and social care support
  around the needs of every member
• Uses Telehealth and Telecare equipment
  strategically to support people to live
  healthier, more independent lives
• Promotes healthy behaviours to all people with a
  modifiable Long Term Condition even those at
  lower absolute risk

16
"It is our legacy to create....... " Jean Bisio
2008 CEO Green Ribbon Health Florida
Birmingham OwnHealth Winners of West Midlands
Regional Health Social Care Award
2008 www.birminghamownhealth.co.uk
17
To summarise
http//www.healthexec.tv/cgi-bin/details.pl?action
progid440