🚨Today in West Devon🚨 @NHSDevonCCG & @Devon_LMC approved iCOPE (Integrated Care for Older People), the UK's first #populationhealthmanagement strategy for older people to be implemented.
/1
We will proactively identify older people across West Devon with reduced physiological robustness (aka medical diagnosis of #frailty) and offer evidence-based interventions & #Personcentredcare to support patients to achieve their goals (see plan on page below) 👇
/2 Image
It's based on @ageingwell @nhsrightcare Frailty Toolkit & is our local answer to #anticipatorycare spec in the @NHSEngland #longtermplan. It is:
👉Proactive & goal orientated
👉Community-based
👉Focusses on prevention
👉Identifies mild frailty so we can intervene EARLY
/3
People with mod-severe frailty will be offered shared Comprehensive Geriatric Assessment (CGA) using shared workforce from #primarycare & #communityservices (or #ambulatorycare/ acute ward if patient is admitted). Shared assessments will improve continuity of care. /4
Furthermore we are hoping to pilot having dedicated older peoples wards in the hospital for each #PCN. This means our locality can be divided into communities based on a PCN footprint, each containing it's own PCN, several #carehomes, an MDT, and acute ward for that community /5
Weekly communication will take place across these services, including inreach to the ward. This will improve continuity and support discharge. Many PCNs, #communityservices, #ambulatorycare, #hospice share same IT (@TPP_SystmOne). This gives informational continuity of care /6
The acute trust also has same IT system as community (SystmOne) and evaluating its capabilities for ward-based use. Same true for care homes thanks to our Devon #digitalstp (thanks in particular to @bearmccormick). This will give further informational continuity. /7
So in summary:
👉proactive population health management with heavy focus on prevention and #PersonalisedHealthcare
👉Vertical integration of healthcare providers around a PCN community footprint = continuity
👉 Sharing of assessments and workforce = more continuity
/8
None of this would have been possible without colleagues in:
👉IG: --> robust #informationsharing across locality @claireabatten
👉IT: refining IT so it harmonises across providers @KerleyAngie
👉UHP BI team: Evaluation of service with shared datasets across acute/community /5
👉Shared vision of staff & leaders in primary care, secondary care, community services, the CCG, and @plymouthcc 🙏👏👏

So to everyone involved in every single part of iCOPE- a massive thank you. We would not be where we are now without you

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More from @DavidAttwood12

23 Jan
Apologies for inactivity on Twitter. Our #PlymouthCOVIDCollaborative has been hard at work. The task: vaccinate 80 carehomes, 1800 patients, 2700 staff, across 17 GP surgeries, in 5 #primarycarenetworks IN 10 DAYS. What follows is a brief chronology of events /1
Tues 5th Jan: I was asked to join amazing #Plymouth PCN COVID Collaborative team as #COVIDvaccination coordinator for #carehomes.
Thursday 7th Jan: 1st 400 doses of #astrazenecca arrive
Monday 11th Jan: 1st of 80 #carehomes to have AZ vaccines piloted in @PathfieldsMG PCN
/2
Tuesday 12th Jan: 3 other #primarycarenetworks - Drake, Waterside, and Mayflower - also pilot. Our city works well together and, true to Plymouth form, our #vaccteams are a mixture of teams from #primarycare and #communityservices (courtesy of @livewellsw) -thanks Livewell 🙏 /3
Read 14 tweets
26 Jun 20
I hear the words “Population Health Management” (PHM) MIS-used a lot. The clue is in all 3 words esp. the middle one. The goal is to focus on population HEALTH NOT getting older people out of hospital as fast as possible- that would be called Service Utilisation Management /1
The central tenant of PHM is that healthy people do not utilise healthcare—> reduction in healthcare utilisation. If we ask older people what matters to them, they nearly always say: to be happy, healthy and independent in a dwelling of their choosing for as long as possible /2
When designing a service based on PHM principles all we then have to do is work out the evidenced based interventions that support older people to be happy healthy and independent for as long as possible /3
Read 10 tweets

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