.

Managing demand through prevention The Newquay Pathfinder and Living Well Pioneer

How we got here

! Changing lives o! Reduce and avoid layers o! Evidence base o! Co-production o! Self care and self management o! Resource maximisation ! Steady On ! Get Well, Stay Well ! Active ageing ! Peer led support ! Memory support and cognitive stimulation ! Supported transport

This is who we are working with

Identification of People - Learning

Timing 3 years of life event Willingness to engage

Application of Criteria Risk Stratification

Complex Care Review

Join the program

Introducing Betty
Diabetes Hypertension Stroke Urinary Tract Infection Respiratory issues Low mood afternoons/weekends Embarrassment state of her home Social network - will not invite people around, worried about falling outside Fear doesnt want to leave her home Lack of confidence doesnt like the way she looks anymore Dependency nurses/social care/GP is her network

Dependency cycle
Regular GP Visits District Nurse 3/week Community Matron Carers 3/day Regular unplanned hospital admissions Watching TV 8+ hours/day
Increasing Isolation and dependency Increasing Acute Admission

Increasing Primary Care

Increasing Social Care

Increasing Clinical Community Care

What we do
Guided conversation, motivation, goal setting !! To get to know more people !! To get out of her home !! To buy her own food !! To get the building work done !! To do something for her Part of clinical and social care meetings; shared management plans and outcomes Requested pharmacy check Telehealth Find list of builders & help put together a schedule Exercise buddy Coffee mornings, lunch clubs, shopping trips, counselling sessions, peer befriending, benefits, carer support, transport

Reversing dependency
What Betty does now Manages her building work Runs coffee mornings Organises theatre trips Peer supports other Pathfinder people with COPD Uses NHS and social care resources less
Condition Management Plan Self Caring and Self Managing

Guided Conversation

Breathers Group, Coffee Morning

Reducing number of hospital admissions

This is what the team looks like

Practice CLworker role: ! Shared management plans ! Broad support planning and brokerage across all sectors ! Proactive communication and practitioner liaison ! Coordination and managing volunteer/community support ! Ownership and development of anticipatory support and care planning ! Independent self care and self management ! Building social networks and social capital ! Developing activity based support

This is how the team works

This is how the team supports

Changes in Practice
This has opened up a whole new opportunity for new ways of working within the NHS as a health team we have benefited from the involvement of the volunteers. This has been educational where I thought patients dependency would naturally increase with a little input we have seen dependency decrease Dr Anderson Newquay

Changes in Practice
The PIP workers help people to manage their own conditions in their own home and prevent hospital admissions. We are getting new ideas, learning and developing as district nurses Lucy Clement District Nurse Team Leader

Measuring impact
Improved quality of life Outcome 1 ! Individual self worth and social capital ! Improved connectivity ! Community resilience ! Enabling economic viability Interdependent teams Outcome 2 ! Greater satisfaction ! Enabling decision making Financial Outcome 3 ! Reducing/compressing spend ! Identifying funding shifts across system

Outcome 1 Quality of Life

16% 20% 12% 8%

23%

Outcome 2 - Integrated working

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$

Outcome 2 - Integrated working

<=$>+7'+3+$)*&)$)*+$-&)*./(+,$0&%$)*+$6'%%'/8$ 7'/2$'/$%+,3'?+%$91,$)*+$%+,3'?+$:%+,@$A16>'/+($ 0')*$*+&7)*$%:--1,)$&/($%:--1,)$9,16$B(:7)$ ?&,+$&/($0+77>+'/8C$)*+$-&)*./(+,$'%$&>7+$)1$-:)$ )*+$-+,%1/$&)$)*+$?+/),+$19$-,1?++('/8%$&/($ ./($1:)$0*&)$)*+4$0&/)$&/($%:--1,)$)*+6$)1$ 6&/&8+$)*+6%+73+%$&/($)*+',$?1/(';1/%$)1$)*+$ >+%)$19$)*+',$&>'7';+%@$D*'%$'%$'/?,+('>74$ 6+&/'/89:7$)1$)*+$'/('3'(:&7@E$!"#$%&"$'"($$ $

F:66&,4$
! Counter Factual Modeling ! Non Elective Admissions Spend ! 30/66% Reduction ! LTC Non Elective Admissions Spend ! 40/63% Reduction ! Historic Spend Modeling ! Under Scenario 1 ! 56% Reduction ! Under Scenario 2 ! 25% Reduction

F1?'&7$A&,+$

G@"#,+(:?;1/$'/$?1%)$19$1/81'/8$ ?&,+$-&?2&8+%$ $ H+(:?;1/$'/$+5-+?)+($(+6&/($ 91,$/+0$-&?2&8+%$19$?&,+$ $ $

Thank you