Part Public
Paper 8
Cover Sheet: Governing Body
Date
Wednesday 2nd July 2014
Title of paper
Ealing ICE Review Report
Presenter &
Organisation
Avani Devkaran/Usha Prema
Author
Ealing ICE Review Steering Group
Responsible Director
Kathryn Magson
Clinical Lead
Dr Raj Chandok/Dr Mohini Parmar
Confidential
No
(items are only confidential if it is in the public interest for them to be so)
The Governing Body is asked to:
To note and approve the final Ealing ICE Review Recommendations and next steps for implementation.
Summary of purpose and scope of report
Ealing CCG is currently undertaking a major transformation change programme of work as part of the SaHF,
Whole Systems Integration (WSIC) and Better Care Fund (BCF). The ICE Review has been undertaken within
this wider strategic context and we have engaged with a whole range of stakeholders and all key partners,
including key professionals from primary, acute and community services from EHT ICO, as part of the coredesign of the pathway. It has also become increasingly obvious the overlaps and the need to align the
pathway between the co-design of Care Co-ordination as part of the WSIC and proposed new model of ICE.
The review has therefore identified a model of care to be implemented by April 2015 with the work
happening in two phases:
Phase 1 (within existing resources, investment and workforce): For winter 2014 (in place by October
2014): Intensive rapid response services for patients in the community and in hospital, coupled with
short-term stabilisation support (i.e. 12 weeks) to prevent re-emergence of need enabled through:
•
•
•
•
•
Full use of existing contracted capacity, particularly for patients in the community;
Agreement on criteria for 2 hour and 24 hour rapid response times
Clear joint agreement and medical responsibility between GP/Consultant/ICE medics if GP refers to
jointly manage the acuity of all patients; and
Strong communications, dialogue and sharing information and awareness of intermediate care
services between clinicians in primary care, community and in hospitals focused on the needs of the
patient.
7 day working – the service should be available 08:00 to 22.00, 08:00 to 22.30 in A&E
Phase 2 (potential reprofiling of resources): For April 2015: A new model of care commissioned in line
with Whole Systems Integrated model and the need for increased nursing and social care support
including:
•
•
•
•
Clear integration within wider Whole Systems Integrated work;
Agreed contract with key measures of success and mechanisms for responding to over or under
performance;
Integration with existing services in the community where appropriate; and
Clear operational alignment with Care Navigation and Care Co-ordination model of care.
Quality & Safety/ Patient Engagement/ Impact on patient services:
Patients have access to the full range of support to ensure they are stable and able to remain at home
before moving into ‘long term’ care co-ordination and / or self-management along the whole systems
pathway
The Review engaged with a range of stakeholders, from primary care, secondary care and community
services. The Review held two stakeholder engagement days, which included frontline staff representatives
from the Rapid Response Team, Magnolia Ward, and the Short Term Rehabilitation Team from ICE. It also
took into consideration patient views of the ICE Service.
Financial and resource implications
The Review recommends the implementation of the recommendations into two phases. Phase 1 to be
implemented within current EHT ICO contract 2014/15, within existing resources, investment and
workforce. Phase 2 to be considered within the context of 2015/16 commissioning intentions and planning
for the WSIC care navigation and co-ordination Workstream.
Equality / Human Rights / Privacy impact analysis
None
Risk
Phase 1 not implemented in time for winter 2014
EHT ICO rejection of shared medical responsibility between ICE and GP for those patient referred by GP.
EHT ICO requesting additional funding for implementation over and above current investment.
Supporting documents
Ealing ICE Review Report – June 2014.
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name
Executive Management &
Innovation Committee
Date discussed
26/06/2014
Outcome
Recommendations agreed and to present to
GB.
June 2014
The Intermediate Care Service Review
Report
Contents
About this report......................................................................................................................... 4
Executive Summary ................................................................................................................... 5
1.
The Intermediate Care Service Review Project ................................................................... 8
1.1. Review background ............................................................................................................................ 8
1.2. Review objectives and expected outcomes ....................................................................................... 8
1.3. Deliverables........................................................................................................................................ 8
1.4. Review approach................................................................................................................................ 9
1.5. Commissioning intentions 2014/15 ................................................................................................... 9
2.
Current model of ICE .........................................................................................................10
2.1. Current service in Ealing .................................................................................................................. 10
2.2. Current referrals, activities and performance ................................................................................. 10
2.3. Patient and carer satisfaction .......................................................................................................... 10
2.4. View from provider, commissioner staff and referrers ................................................................... 10
2.5. Benchmarking best practice............................................................................................................. 12
2.6. Opportunities ................................................................................................................................... 13
3.
Proposed Service...............................................................................................................15
3.1. Vision and principles ........................................................................................................................ 15
3.3. Multi-disciplinary virtual care team ................................................................................................. 17
3.3. Medical responsibility ...................................................................................................................... 17
3.4. Integration with other services ........................................................................................................ 18
3.5. Changes to the current model ......................................................................................................... 19
4.
Recommendations and next steps .....................................................................................20
Annex 1: Current model of care
Annex 2: Overview of savings against key performance indicators
Annex 3: Referral activity: initial model of predicted activity
Annex 4: Detailed analysis Patient and GP survey, commissioners and providers feedback
Annex 5: Participants in co-design workshops
Annex 6: Medical Responsibility Comparison
Annex 7: Governance
Annex 8: Implementation Timescales
2
3
About this report
Ealing CCG and Ealing Council worked together with the Ealing Integrated Care organisation to
undertake a review of the current provision of Intermediate Care services to patients at risk of
hospital admission and those who could leave hospital with additional support in the community.
This review is part of collaborative working between commissioners and providers to shape the
best service for patients in Ealing who have short term intensive needs that require a rapid and
comprehensive response.
This report outlines the findings from the review, including the agreed new model of care,
timescales for achieving this and an implementation approach retains a focus on clinical
leadership and co-design between providers, commissioners and patients.
Dr Alan Hakim
Lead/Chair
Dr Raj Chandok
Clinical Lead, ICE
Dr Mohini Parmar
ECCG Chair
Dr Shanker Vijayadeva
GP
Dr John Riordan
Secondary Care Representative
Kathryn Magson
ECCG Managing Director
Dr Avani Devkaran
GP Registrar and Darzi Fellow
Usha Prema
Commissioning Development Manager
Elizabeth Youard
Community Services Programme Director
CWHHE CCG Collaborative
4
Executive Summary
ICE Service review
Ealing CCG and local authority, in partnership with their partner providers, are transforming the
model of provision of health and social care provision across the borough. This is grounded in a
‘whole systems’ approach to the right care, in the right place from the right team. The
Intermediate Care service is crucial to this model: responding quickly to people at risk of
admission into hospital and supporting those in hospital to come home is core to care closer to
home.
Within this context, this project was launched to review the success of a new model of
intermediate care, introduced in October 2012 as part of Ealing’s Out of Hospital Strategy – and
to determine the right model of provision for the future.
The existing ICE service is an essential part of the Ealing array of provision, designed to provide
high quality patient care for those requiring coordinated integrated rapid response services in
the community and additional support to facilitate discharge from hospital. Stakeholders from
across Ealing came together to consider the current delivery model, identify what works well,
and agree what the future model of provision should look like, particularly given the wider
service transformation underway.
The current ICE service is focused on ensuring the following outcomes for patients in the
community who are at risk of hospital admission and those coming out of hospital requiring
additional support:




Prevention of admission / reduction in length of stay
Improved patient experience and satisfaction
Improved carer experience
Better clinical outcomes
Approach to the review
To understand how the service could be improved the ICE review panel collated feedback from
providers, commissioners and referrers in four ways:




Existing quantitative data - analysis of service data and admissions data;
Provider and commissioner working sessions to establish areas for improvement within
the service;
Gathering GP experiences via a survey; and
Benchmarking the current model against comparable services to identify improvement
opportunities.
Review outcomes
The aim of the service is not changing. The ICE service still plays a fundamental role in the
wider provision of support for patients in Ealing – and specifically needs to:

provide care and support for people at home who are risk of admission to hospital in the
short term within two timescales (response four hours for the most urgent and 24 hours for
others)
5


facilitate the discharge of people from hospital or inpatient rehabilitation into their own
homes who require some additional support for the short term for this to happen,
Ensure that in both cases the ‘step-down’ in the level of support is smooth and does not put
the patient at risk of requiring intensive intervention in the short term.
The review therefore identified a revised model of care, with associated changes to workforce,
medical responsibility and length of provision. The review proposes a service with four core
features:




Model of care – a service which provides immediate intensive support (in 2 hours for
some patients and 24 hours for others) in a comprehensive manner, backed up by short
term nursing, therapy and social care support to ensure patient is stable in the medium
term. It will have a degree of fluidity in the service to enable patients to move across
areas of the service depending on the intensity of the support they require;
Collaborative working – the service will remain a stand-alone team that interfaces
closely with the wider Care Co-ordination service, GPs and others to support ‘shared
patients’ and to facilitate smooth transition from one to the other;
Communications – referrals and clinician-to-clinician discussions for patients who are
at risk of admission to hospital in the next few days or whom require additional support
to return home from hospital; and
Workforce – the right mix of nursing, social care, therapy and other staff to enable
immediate intensive support for approximately seven days, and short term support for up
to twelve weeks.
Recommendations
The review has therefore identified a model of care to be implemented by April 2015 with the
work happening in two phases:
Phase 1 (within existing resources, investment and workforce): For winter 2014 (in place
by October 2014): Intensive rapid response services for patients in the community and in
hospital, coupled with short-term stabilisation support (i.e. 12 weeks) to prevent reemergence of need enabled through:





Full use of existing contracted capacity, particularly for patients in the community;
Agreement on criteria for 2 hour and 24 hour rapid response times
Clear joint agreement and medical responsibility between GP/Consultant/ICE medics if
GP refers to jointly manage the acuity of all patients; and
Strong communications, dialogue and sharing information and awareness of
intermediate care services between clinicians in primary care, community and in
hospitals focused on the needs of the patient.
7 day working – the service should be available 08:00 to 22.00, 08:00 to 22.30 in A&E
Phase 2 (potential reprofiling of resources): For April 2015: A new model of care
commissioned in line with Whole Systems Integrated model and the need for increased
nursing and social care support including:



Clear integration within wider Whole Systems Integrated work;
Agreed contract with key measures of success and mechanisms for responding to over
or under performance;
Integration with existing services in the community where appropriate; and
6

Clear operational alignment with Care Navigation and Care Co-ordination model of care.
Recommendations
As an output of this review Ealing CCG, Ealing Local Authority and Ealing ICO will establish an
Implementation Group to take this work forward and collectively deliver on the outcomes above,
as an integral part of the Whole Systems Integrated Model, including links with the development
of the integrated nursing model. The Implementation Group will report to the Urgent Care Board
and through them to the Joint Management Team and the Health and Wellbeing Board.
The work will continue to be framed by the principles that have guided the review:



Collaborative development including provider, commissioner and service users;
Focus on outcomes for patients – high quality care close to home with a focus on
sustainability and reablement; and
Being iterative and able to change to improve, particularly learning from the winter
provision for the model commissioned in April 2015.
7
1. The Intermediate Care Service Review Project
1.1. Review background
This document summarises the findings from a review of the Ealing Intermediate Care service
and outlines areas of opportunity for collectively achieving improvements for patients in the
community and in hospital.
The service provided by Ealing Hospital Trust (EHT) Integrated Care Organisation (ICO)
commenced in October 2012 with an investment of £4.32m. ICE is a key Quality Innovation
Productivity and Prevention (QIPP) Scheme for 2013/14.
Through Whole Systems Integrated Care and the Better Care Fund Ealing is implementing an
new model of provision across Health and Social Care. This has created the need – and
opportunity – to ensure that ICE provides a service which is in line with the future plans for
provision of care for the residents of Ealing.
1.2. Review objectives and expected outcomes
The objective of this review was to assess the current ICE service model and agree priority
areas for improvement particularly within this context. To achieve this, the review looked at:



The current service;
operational delivery successes and challenges; and
gaps in the service and future model of provision.
The review proposes an improved, effective and efficient Intermediate Care service that works
as a core part of the emerging Whole Systems integrated care in Ealing. The new service
model will deliver:








immediate and short term support to people at risk of admission into hospital, including
those identified by GPs, social workers and other professionals in the community;
nursing, social care and therapy services to stabilise patients and then ‘move them on’ to
independence and / or long term support;
a service that provides care for all residents from Ealing;
clarity about medical responsibility and clinical delivery;
agreed criteria for use of the ICE service – and discharge into self-care, care coordination services, care navigation or other forms of support;
maximised and prioritised use of resources within the service;
primary care confidence in responsiveness and quality
Value for money.
1.3. Deliverables
The key deliverables for this review1 are:


1
Whole systems pathway ‘As Is’ and ‘To Be’ process map;
Benchmarking examples of best practice
ICE Service Annual Review Scope v6 Item 2
8

Short, medium and long-term recommendations for achieving the new model
1.4. Review approach
The review has been undertaken for Ealing Clinical Commissioning Group (ECCG) as the
commissioners of the service, supported by PPL Consulting. The approach has been
purposefully collaborative and included numerous joint sessions between commissioners and
providers. Both qualitative and quantitative methods of measurement were used to establish
the gap between the intended and actual performance of the service and to develop the new
model of care.
Data collection methods are:




Existing quantitative data - analysis of service data and admissions data;
Provider and commissioner working sessions to establish areas for improvement within
the service;
Gathering GP experiences via a survey; and
Benchmarking the current model against comparable services to identify improvement
opportunities.
1.5. Commissioning intentions 2014/15
The commissioning intentions set out how the ICE service will fit within the wider Ealing model
of care. There is a clear ambition to scale up the service and in particular to deliver high quality
immediate and short term support to people in the community at risk of admission to hospital.
Detailed investment decisions await the outcome of this review and the development of the
revised specification. The scale-up of this service will depend on a number of factors; the aim is
to develop it collaboratively with Ealing ICO in both phase 1 (winter 2014) and phase 2 (April
2015).
9
2. Current model of ICE
2.1. Current service in Ealing
ICE is an integrated service across health and social care. It encompasses a number of
services including: Single Point of Access (SPA), Rapid Assessment, Rapid Response,
Rehabilitation, Reablement and Step-up bedded service supporting both medical and physical
needs (Annex 1). The service places the patient at the center of the coordinated model of care,
improving patient and carer experience. By providing high quality clinical care to patients at
home the number of urgent hospital attendances and the length of hospital stay will be reduced.
2.2. Current referrals, activities and performance
Referrals and activity October 2012 – March 2014
A comparison of the current level of ICE performance in relation to the initial modeling and
target set for the service indicates a low level of activity (see Annex 2 and 3).
2.3. Patient and carer satisfaction
A Trust wide ICE Patient Experience survey was conducted between September and November
2013. A total of 100 questionnaires were reviewed for the Rapid Response (RR) and Supported
Discharge (SD) team. Generally the response to questions was very positive (over 80%).
(Annex 4).
Patients rated the care they received very highly:


RR 98% Excellent or Very Good
SD 94% Excellent or Very Good
Areas for improvement were:


Patients having contact details for the service (RR satisfaction 69%)
Patients being informed of changes to appointments (RR satisfaction 67%)
2.4. View from provider, commissioner staff and referrers
Two working sessions and a GP survey (Annex 4) were conducted to identify the key areas for
improvement within the service. Approximately 30 participants attended the sessions including
representation from health and social care commissioners and providers (Annex 5). 12% (38 out
of 327) of the GPs in Ealing responded to the survey providing coverage across the 7 localities.
We identified what has worked well:
•
•
•
•
Service users experiencing better quality targeted care
Effective working relationship between ICE and A&E
Effective communication channels between ICE and Reablement services
Improved discharge pathways
Our stakeholders identified internal areas for development that could address underlying issues
for the operational delivery of intermediate care services. We also identified five areas for
improvement:
10






overall model of care - patient journey from access to discharge;
collaborative working;
communications including information and data sharing;
staffing recruitment and retention; and
Skills, roles and responsibilities.
7 day working
a) Model of Care
The participants determined that the current model does not meet the needs of different patients
with diverse needs. Specific areas for improvement included the need to:




broaden access for Ealing patients from hospitals beyond that of EHT;
broaden existing referral pathways including but not limited to Imperial, North West
London Hospitals Trust and Hillingdon A&E;
improve the Rapid Response service available across the borough through work
alongside primary care services; and
Improve clarity regarding the patient cohort deemed appropriate for the service.
b) Collaborative working
Participants identified a need to develop stronger links between services and sought improved
integration with external organisations. They highlighted disparity between GP practices in the
level of engagement with the service, resulting in:


a variable number of referrals; and
A lack of clarity regarding the role of social services and community pharmacists in
delivery.
c) Communications
The feedback received indicated a lack of awareness across Ealing GPs regarding the function
of the service. Ineffective marketing was identified as a contributing factor in the resultant low
utilisation of the service.
The majority of GPs perceived that – when used – the referral process to be easy or satisfactory
with the main barrier identified as information duplication. In particular the need was identified
for an effective information system, replacing fax and emails, to share the referral form.
d) Staffing recruitment and retention
Participants in the survey and workshops indicated that the service requires workforce
development – primarily around numbers – to meet the requirements for 7 day working.
Recruiting and retaining staff remains a challenge for the service due to the complexity of the
responsibilities and roles outlined within the multi-disciplinary working model. The feedback also
identified a need for training support.
The review identifies a greater diversity of roles within the multi-disciplinary team as being a
potential area for future improvement within the service.
e) Skills, roles and responsibilities
The feedback identified the need for clear clinical leadership, consistent multi-disciplinary
assessment of need between the referrer and the ICE staff, and the need for a more efficient
handover process back to the referring GP at the time of discharge.
11
2.5. Benchmarking best practice
This section sets out a comparison of Ealing’s current model with some of the similar services
offered in other boroughs. Table 1 provides an outline of our current service model against
comparable services to identify opportunities for improved design.
Key comparative service examples include:



STARRS – Brent and Harrow
ICRS - Hounslow
Integrated Primary Care, Rapid Response Service – Camden
(For detailed information see Annex 4.)
Table1. Intermediate care services comparison
Themes
Ealing
Hounslow
(Intermediate Care
(Integrated
Ealing)
Community Response
Service-)
a) Model of Care
Referrals accepted
from GP, A&E
departments, Urgent
Care Centers.
Service responds to
patients in non-acute
bedded units.
Mon - Fri 8am-8pm
and reduced service
over the weekend.
Referrals accepted
from Urgent Care,
Emergency
Department & Acute
Assessment Centre,
Acute hospitals,
Rehabilitation facilities,
GP, Community health
practitioner, LAS,
Social Care
practitioner.
Service responds to
patients at Charing
Cross, Ashford, St
Peters and Ealing
Hospital.
Camden
(Integrated Primary
Care, Rapid
Response Service)
Harrow & Brent
(STARRS)
Referrals accepted
from a range of
providers.
Referrals accepted
from clinicians or
social care
professionals.
Service responds to
patients in non-private
hospitals within the
Greater London area.
Mon – Fri 8am8pm. Sat – Sun
9am-3pm.
Mon - Fri 9am-5pm.
Service available to
Camden residents
living at home
requiring immediate
intervention.
7 days per week 7am7pm.
Service available to all
service users (18+)
registered with a
Hounslow GP.
b) Collaborative
working
c) Communications
Integrated operating
methods so that the
patient experience is
that of a single
service.
The provider is
responsible for raising
awareness of the
Integrated
operating methods
so that the patient
experience is that
of a single service.
The provider is
responsible for
raising awareness
12
Themes
Ealing
(Intermediate Care
Ealing)
Hounslow
(Integrated
Community Response
Service-)
Camden
(Integrated Primary
Care, Rapid
Response Service)
service and managing
issues which impact
on referrals.
e) Skills, roles and
responsibilities
Rapid Response
assumes medical
responsibility for
patients for as long as
they are in the
service. Medical
responsibility
transfers to the
patients GP upon
referral to short term
services.
Clinically led MDT.
Medical responsibility
shared with GP.
Harrow & Brent
(STARRS)
of the service and
managing issues
which impact on
referrals.
Medical
responsibility
remains with the
GP where STARRS
deliver services
within a community
setting.
Medical responsibility
within the rapid
assessment and
response unit lies
with the Intermediate
Care lead clinician.
Accountable senior
clinical leadership.
*For further detail see Benchmarking Intermediate Care document.
2.6. Opportunities
We drew together a wide range of insights from all the research and distilled these insights into
five opportunity areas. These areas are intended to provide a platform for the service design
from which to generate ambitious new ideas, combining the aspirations of the service with the
strategic priorities in Ealing.
Table 2. Opportunity areas
Area
What could be improved
a) Model of Care
How could we improve
a) Develop the existing service to
respond better to patient need.
b) SPA process
c) The service to be equitable to all
Ealing residents.
d) The service to differentiate
between users based on urgency
of need.
e) Increased referral rates from
health and social care
professionals.
f) Immediate care followed by short
13







Develop a single assessment process with clear
access pathways.
A response appropriate to the urgency of need.
Streamline SPA processes.
Widen the referral routes into the ICE service.
Proactive case identification either into or out of
hospital.
Put in place provision for 7-day intensive support
followed by up to 12 weeks of ‘step down’ support
prior to discharge / moving on
A greater role for social workers, reablement staff
and community pharmacists in multi-disciplinary
Area
What could be improved
How could we improve
term provision to ensure stability
before discharge or handover
b) Collaborative
working
c)
Communications
d) Staffing
recruitment and
retention
e) Staff skills and
roles
working.
a) Alignment of ICE with wider
services (e.g. WSIC).
b) Work with other services based in
A&E’s adjacent to Ealing.

a) Communication channels
between ICE and the community
services.
b) Clarity of purpose and role for
GPs
c) Data sharing within the MDT.
d) Data sharing between the service
and referrer.
e) Awareness of the service
amongst all providers to increase
appropriate referrals for all
patients across the borough.
a) Extended hours of service
delivery.
b) Mix of skills including high quality
nursing, social care and therapy
services
c) Recruitment for the ICE team.
d) Involvement of social care.

a) Further consideration to how
medical responsibility is shared
by the GP and the ICE service.
b) Flexible working practices
including across teams.










Develop contractual commitments that govern ICE
as an enabler for integrated working.
Explore the connection between LAS and ICE.
Develop the data sharing infrastructure to support
the service.
Advertise the role of the service across health and
social care settings within the borough, particularly
in primary care
Design a flexible sufficiently resourced staffing
model to cover the 7 day working service that
provides immediate and short term resource
Introduce team based social workers.
Greater engagement of the voluntary sector.
Explore opportunities to ‘share’ resources with
emerging care navigation and care co-ordination
teams
Agree roles and responsibilities for different team
members.
Agree medical responsibility and clinical provision
Ability to work flexibly, off site and in people’s
homes.
Regular training and education to up-skill and multiskill staff.
Not all of these changes are possible or appropriate for Ealing but many of them inform the new
service model proposed below.
14
3. Proposed Service
3.1. Vision and principles
Our future service will support people to receive care at home whenever possible by ‘providing
an effective and efficient whole system integrated Intermediate Care Service wrapped around
primary care.’
Based on the opportunities identified in section 2 and through consultation with colleagues
across the system, principles have emerged that will guide the future design and development
of the service. Stakeholders agreed on the following principles for the future service:










Focused on supporting people to remain at home safely and comfortably – and / or to
come home quickly and safely
Flexible and responsive to patients’ evolving needs;
Provision (including referrals and planning) done by a multi-disciplinary team;
Responds to the patient within appropriate timescales according to the patients need;
Access to specialist support as needed;
Seven day working;
An effective supported discharge system from the service;
Smooth connections between different services (e.g. WSIC, OPRAC etc.);
Alignment of services to GP networks; and
As close to single integrated patient records as possible.
The key aims of the service remain:




Provide responsive high quality support for clinical, social and functional needs to
prevent hospital attendances and admissions;
Reduce unnecessary length of stay in hospital;
Provide immediate and short term support to enable patients to be stable and confident
at home (whether moving on to ‘self-care’ or to a long-term package of support) with
some of this support being provided within 2 hours and other patients receiving support
within 24 hours; and
Deliver integrated coordinated care that is patient centered, coordinated and offers
continuity of care to high need patients.
Figure 1 overleaf illustrates the agreed ICE model of care.
15
Figure 1 Agreed ICE delivery model
The new service has six core features:
1. Rapid response (2 hours for some and 24 hours for others) for patients who are at risk of
hospital admission in the immediate or short term without the provision of additional
nursing, social care or therapy support
2. Support for patients who are able to be discharged from hospital with similar additional
support
3. Services need to be responsive to provide both rapid comprehensive high end support
immediately and comprehensive nursing, therapy and social care support for a short
period, adding capacity in effect to the services that primary care, community health and
social care are already offering;
4. As patients are likely to move between the ‘differing intensities’ of support there should
be a fluid way to do this i.e. a ‘virtual care’ team providing both immediate and short
term care;
5. The ICE service remains a stand-alone team from the wider Care Co-ordination service
but interfaces closely around shared patients; and
6. Immediate intensive support is for approximately seven days and ‘short term’ support for
up to twelve weeks (as in figure 1 above)
16
3.2. Multi-disciplinary virtual care team
The service is delivered by an ‘ICE Care Team’ with a skills mix including health, social care,
therapy, medicines etc. The service will have access to specialist professionals to assist where
required. Figure 2 demonstrates the core services with rapid access to specialist services.
Figure 2. ICE team
This team is similar to the emerging multi-disciplinary team at the heart of the Ealing Whole
Systems model. It will sit alongside this more long term team. Work is underway to define
exactly how the two services will interact and intersect, including options around sharing
resources and expertise.
3.3. Medical responsibility
Joint medical responsibility for patients who are in the ICE service is critical. The approach is to
have a clear joint agreement and medical responsibility between GP/Consultant/ICE medical
team to jointly manage the acuity of all patients. The approaches are:


Patients referred from the community: for patients who are referred from the
community their registered GP the approach is to have a clear joint agreement and
medical responsibility between GP/consultant. This is a change to the current model of
care.
Patients referred from hospital: for patients who are referred from hospital, either from
A&E or being discharged from an inpatient bed, the ICE team will have Medical
Responsibility. This will transfer back to the GP once the patient is ‘discharged’ from the
17
ICE team, whether they are discharged into self-management or into a long term
package of care. This is no change from the current model of care.
Annex 6 compares current and future Ealing Medical Responsibility to other models of care.
3.4. Integration with other services
ICE is a core part of the emerging Whole Systems model of care in Ealing where patients
receive appropriate levels of care co-ordination and care navigation according to their needs.
Figure 3 shows this emerging model. There is still discussion around the boundary between the
12 week provisions critical to the ICE model (see red box figure 3).
There are also activities underway to agree which existing services may form part of this 12
week provision.
In summary the Whole Systems work and the ICE work are coming together around a number
of outstanding questions:
1) What is the boundary between ICE and wider care co-ordination particularly at the high
end of care co-ordination?
2) What existing services may be incorporated into the ‘short term’ aspect of ICE / high end
aspect of care co-ordination?
These are being addressed in the short / medium term as part of the wider BCF activities being
overseen by the Urgent Care board and the Joint Management Team.
Figure 3 ICE in the wider context
Need /
Risk of admission
ICE
Up to
7 days
Integrated Care / MDT
Up to
12 weeks
Care co-ordination
Intensive support
MDT support
Care
navigation
Self management
Identification and support for dementia and Falls runs throughout
Population (illustrative)
18
3.5. Changes to the current model
The proposed new approach to Intermediate services in Ealing requires a number of
fundamental changes to the current model. The population being served (339,000) – and the
types of services – will expand particularly within the ‘short-term’ support that follows immediate
response. Table 3 highlights the key changes to the current model and how this will be different
for patients.
Table 3. Key changes to the current model
What has changed
Services
included in
ICE
Access
How is it different for patients
Short term support package is
likely to require respecification and redesign of
some existing services
currently outside of the ICE
service (e.g. District Nursing,
Rehabilitation and
Reablement)
More flexibility in the criteria
for accessing the service
Patients have access to the full range of support to ensure
they are stable and able to remain at home before moving
into ‘long term’ care co-ordination and / or self-management
Responsiveness of the ICE
model to the needs of patients
in the community
A service that operates within 2 hours for some patients
and 24 hours for others
A service that operates 7 days/week.
Care planning will involve Social Services and Community
Pharmacists.
Single assessment undertaken in their ‘home’ environment.
Home visits from health and social care professionals.
Increased access to the service through an enhanced
referral ability amongst professionals.
A consistent referral route into the system.
Access to a direct patient advice line.
Referral
Broaden referral pathways
engaging with hospitals
outside of the borough
Cohort
Multi-disciplinary approach to
determining the suitability of
referrals with feedback given
to the referrer
Clear joint medical
responsibility
Differing levels of provision within the service to meet
patient need.
Access to the service based upon registration with a GP in
Ealing.
For GP referrals there is a clear agreement joint medical
responsibility GP/consultant ICE Team to manage the
acuity of patients.
Professional responsibility is
shared by health and social
care
A clear Single Assessment Process enabling the patient to
tell their story once.
A seamless experience of care provision across the service
(contractual agreements).
Improved access to and visibility of social workers.
Responsibility
19
4. Recommendations and next steps
The ICE review sets out the outcomes that commissioners want to see by April 2015. The
detailed steps to achieving this will be co-designed and agreed by the implementation group
detailed below. The recommendations and the outcome and delivery of the short term
improvements will also inform Ealing CCG’s commissioning intentions for 2015/16 and beyond.
The vision is set within the context of Whole Systems Integrated Care (WSIC) and support. The
review acknowledges the improvements required in the current model of delivery to achieve the
long term vision will be in phases, as it will be part of a journey to establish the full model of
care.
Delivery is against two phases as set out below.
A) Phase 1: Immediate and short term response in place for Winter 2014
Recommendation
Put in place immediate and short term response to patients in the community and being
discharged from hospital ensuring full utilisation of current resources and ‘top-up’ of
provision where necessary and possible
 Ensure full use of existing contracted capacity, particularly for patients in the community.
 Implement response timescales of four hours for some patients and 24 hours for others
 Ensure that GPs, consultants, ICE and others agree on joint medical responsibility from
referral to discharge
 Set up and facilitate mechanisms for opening referrals from other professionals in the
Community.
 Put in place multi-disciplinary team including enhanced nursing, social care and therapy
resource to ensure support to people in the community and safe supported discharge.
 Greater awareness of the ICE service by all potential referrals to increase use of capacity.
 7 day working: 08:00 to 22.00 and In A&E 08:00 to 22:30
B)
Phase 2: New contract in place for April 2015
Recommendation
1. Put in place detailed delivery model (e.g. wider existing community and social care services to
be included in the model, particularly the provision of services post immediate response)
2. Take forward necessary procurement and contracting requirements, including procurement and
contracting options
Implementation and Governance
It is proposed that the Ealing Urgent Care Board will be responsible for the delivery of the
recommendations under the Urgent Care Programme of Work, reporting to the Health and
Social Care Joint Management Team, Ealing CCG Executive and to the Health and Well Being
Board as part of the integration agenda under the Better Care Fund and the WSIC Programme
of work. The key priority for the Ealing Urgent Care Board will be winter planning for 2014/15,
ensuring the improvements recommended in Phase 1 are delivered and in place for winter.
An Implementation Steering Group will be established to agree an action plan on the details of
the delivery to the timescales for of Phase 1 and Phase 2 of the recommendations. The Group
will utilize current governance mechanisms of the Better Care Fund and Urgent Care Board for
20
reporting and accountability for delivery (see Annex 6). The timescales for delivery of the
recommendations are outlined with key milestones in Annex 7.
The overall aims and objectives of the steering group will be to work within the following
principles:



Agree and put in place building blocks to implement phase 1 and 2 of ICE changes
within the WSIC
Continue to co-produce with providers and patients
Ensuring clinical oversight and governance to support rapid implementation
Proposed membership of the Implementation Group












ECCG Clinical Lead(CRO) – Chair
ECCG Chair
CCG Senior Management Lead(SRO)
Consultant Physician and Geriatrician
Darzi Fellow/GP Registrar
Key frontline staff from ICE Team: Rapid Response Service, Magnolia Ward, Short Term
Rehabilitation
Social Services Reablement Team and Care Management
Executive Director HR and Operations, EHT ICO
EHT ICO Director of Community Services(Ealing)
Network Provider Leads
A&E Representative
Representatives from key community services, such as falls, district nursing.
21
ANNEX 1 - Current model of care
GP management, community services (too well for intermediate care)
RAPID RESPONSE
RAPID
ASSESSMENT
At risk of
hospital admission
SPA
Access /
signposting
Normal place
of residence /
A&E
treatment and
triage
SHORT-TERM
SERVICES
Step-up bed
Intensive
intervention
ALoS 7-10 days
Rehab bed
Up to 6 weeks
rehabilitation
Normal place
of residence
Up to 72hrs
intensive
intervention
Normal place
of residence
Up to 6 weeks
rehabilitation
Acute hospital admission (too ill for intermediate care)
22
Combined
health and
social
services
ANNEX 2 – Overview of savings against key performance indicators
Table1. Key performance indicators
Key performance indicators
Reduction of acute non-elective adult admissions for
patients registered with an Ealing GP per annum (from
2011/12 baseline)*
2012/13
3,600
2013/14
3,800
2014/15
3,900
Reduction in A&E/UCC attendances for adult patients
registered with an Ealing GP against 2011/12
baseline*
875
875
875
* The 2011/12 baseline will be calculated as the out-turn activity for the period 1st July 2011 to 31st March 2012, extrapolated to 12
months, as reported by the ACV. (Source: ICE Future Discussion Paper).
The ECCG and Ealing Hospital Trust (EHT) 50/50 risk sharing agreement identifies that, subject
to actual performance against KPIs (outlined below) either ECCG or EHT will be required to
reimburse
other party for over or underperformance respectively.`
1. Intermediate Carethe
Service
1. Intermediate Care Service
YTD
200
1,000
100
500
0
(100)
April
May
June
July
August
September
October
November
December
January
February
March
0
(200)
(500)
(300)
Non-elective adult admissions - Change 2012/2013-2013/2014
Month / Year
Non-elective adult admissions -2013/2014
Non-elective adult admissions - 2012/2013
Non-elective adult admissions - Change 2012/2013-2013/2014
April
2,440
2,479
(39)
May
2,346
2,625
(279)
June
2,330
2,533
(203)
July
2,470
2,490
(20)
August September October November December January February March YTD Annual
2,395 2,403 2,411 2,418 2,368 2,394 2,191 2,341 28,507 28,507
2,458 2,314 2,425 2,359 2,414 2,487 2,246 2,512 29,342 29,342
(63)
89
(14)
59
(46)
(93)
(55)
(171) (835) (835)
Non Elective Adult Admissions – ICE change from 2012/13 - 2013/14
23
(1,000)
ANNEX 3 – Referral activity: initial model of predicted activity
GP management, community services (too well for intermediate care)
Inappropriate: 688
Activity: 7,570
RAPID
ASSESSMENT
incl. 808 RR to
STS transfers
At risk of
hospital admission
SPA
Access /
signposting
Other intermediate
care services: 1,528
Normal place
of residence /
A&E
treatment and
triage
Activity: 4,546
ACS: 1,950
Tier 2: 1,667
Existing: 929
Activity: 977
ACS: 390 RAPID RESPONSE
Tier 2: 167
Existing: 420
Step-up bed
Intensive
intervention
ALoS 7-10 days
SHORT-TERM
SERVICES
Rehab bed
Up to 6 weeks
rehabilitation
Normal place
of residence
Up to 72hrs
intensive
intervention
Normal place
of residence
Up to 6 weeks
rehabilitation
Combined
health and
social
services
Activity: 808
ACS: 546
Tier 2: 150
Existing: 112
Activity: 3,569
ACS: 1,560
Tier 2: 1,501
Existing: 509
Acute hospital admission (too ill for intermediate care)
COSTS
SPA & RA cost: £114k
Total cost: £3,929
Existing Cost: £1,406k
Add Inv: £2,523
RR non-bed cost:
£1,605k
Non-bed cost: £2,310
Existing: £171k
New: £2,139k
Step up beds cost:
£1,619k
Existing: £1,235k
New: £384k
STS cost: £592k
Current referral activity
Referrals to SPA
A&E referrals
GP referrals
Other source
Appropriate
Inappropriate
Initial activity
model
Activity
2012/13
7,570
15,568
894 (56%)
527(34%)
171 (10%)
1,592
13,976
Activity
(extrapolated)
2013/14
No longer reported
1,336 (61%)
721 (33%)
130 (6%)
2,187
No longer reported
Days
8.78
2.12
28.12
Days
9.62
2.45
33.53
5,354
688
AVG LoS
Magnolia
Rapid Response
Short Term Rehab
24
ANNEX 4 – Detailed analysis Patient and GP survey, commissioners and providers
feedback
ICE Service Review
Detailed Analysis
25
ANNEX 5 - Participants in co-design workshops
Name
Dr Alan Hakim – Lead ICE Review/Chair of Ealing Urgent Care Board
Dr John Riordan - Secondary care Representative
Kathryn Magson – Managing Director
Dr Mohini Parmar – Chair of Ealing CCG/GP
Dr Raj Chandok – Vice Chair of Ealing/Clinical Lead
Dr Avani Devkaran – Darzi Fellow/GP Registrar
Dr Shanker Vijayadeva – GP
Usha Prema – Commissioning Development Mgr.
Nicola Bradley – Head of Continuing Care, ECCG
Clare Laffey – Care Co-coordinator, ECCG
EHT ICO
Paul Stanton – Director of HR, EHT ICO
Jo Paul – Community Services Director
Bill Lynn – Deputy Chief Executive, EHT ICO
Fiona Wisniacki – Lead EHT Emergency Dept. Consultant
Kisha Moore (ED)
Pat Rubin- Interim Head of Operations
Prakash Pote (ED Physiotherapist)
Dinusha Arya (Physiotherapist)
Bev Mitchell- Head of Therapies
Jill McCartney - Service Lead for Claypond’s Hospital and ICE
Angela Brooke – Head of Adult Services
Penelope Johnson - I.C.E Service Manager, Short Term Rehab Team Lead
Linda Narzako - Consultant Nurse
Admission Avoidance Unit and Service Lead IV therapy
Dr David Slovick
Johnny Swartz - Consultant Physician and Geriatrician
Clinical Lead - Department of Medicine for Older People
Patrick Laffey
ICE GPs
RRT
SRT
Sylvie Wood
Bhupender Sethi (Falls Service Mgr.)
Ealing Social Care
Stephen Day
Gail Oliver
Anne MacAdam plus 2 team leaders
Other: Elizabeth Youard
26
ANNEX 6 – Medical Responsibility comparison
Note: Camden is not specified
Ealing (current)
Ealing (proposed)
Hounslow
Harrow & Brent
GP responsibility
Joint GP/ICE Consultant
responsibility
GP responsibility
GP responsibility
The ICRS will accept referrals
from GPs Doctors with
current responsibilities of
care for the patient.
GPs accept medical
responsibility for STARR’s
patients, and will provide
direct contact information for
use by exception.
Medical responsibility will
transfer to the patient’s GP
on referral to short term
rehabilitation services or on
discharge back to generic
community services / primary
care (i.e. any period following
the rapid response elements
of the pathway).
For those patients who are
referred from the community
their registered GP joint
medical responsibility. At the
same time the ICE team will
provide the clinical input
required. This is a change to
the current model of care.
On receipt of referral the
Integrated Community
Response Team will have a
telephone conversation with
the patients registered GP to
agree medical responsibility
for the patient whilst under
the team’s care.
Medical responsibility within
all STARRS services where
care is delivered in a
community setting remains
with the patient’s GP, with the
exception of:
Team responsibility
Team responsibility
Team responsibility
Team responsibility
The Rapid Response
component (Intermediate
Care lead clinician) will
assume clinical/medical
responsibility for the patient
from the point of acceptance
of the referral to the SPA for
For those patients who are
referred from hospital, either
from A&E or being
discharged from an inpatient
bed, the ICE team will have
Medical Responsibility. This
will transfer back to the GP
The ICRS will accept referrals
from GPs Doctors with
current responsibilities of
care for the patient.
NA
On receipt of referral the
Integrated Community
Ealing (current)
Ealing (proposed)
Hounslow
a Rapid Assessment, and for
the duration that the patient is
within this service. Robust
protocols and mechanisms
will need to be set up and
agreed with Ealing GPs to
ensure effective handovers
and excellent communication.
once the patient is
‘discharged’ from the ICE
team, whether they are
discharged into selfmanagement or into a long
term package of care. This is
no change from the current
model of care.
Response Team will have a
telephone conversation with
the patients registered GP to
agree medical responsibility
for the patient whilst under
the teams care.
Consultant responsibility
Consultant responsibility
Consultant responsibility
Consultant responsibility
Acute consultants will be
medically responsible for
Early Supported Discharge
Patients within the Discharge
Support function.
NA
Acute consultants will be
medically responsible for
Early Supported Discharge
Patients within the Discharge
Support function. Handover
of care on discharge will be in
writing via discharge
summary and onward
referrals as appropriate.
1) The Consultant
Community Geriatricians are
responsible for step up
admissions via A&E or where
they have assessed the
patient immediately prior to
admission.
28
Harrow & Brent
2) The Early Supported
Discharge element of the
Discharge Support service,
where cover is provided
through the discharging
inpatient team (acute
consultant adopts MR).
ANNEX 7 – Governance
Health and Wellbeing Board
JSNA, H&WB Strategy,
Integration, ITF
Statutory
Accountabilities
Governance and
Oversight of Integration
Health Watch
NHS Providers
Ealing Whole Systems Integration
Board
Oversight of Project
Delivery
Integration WorkStreams
Ealing Council
NHS Ealing CCG
Governing Body
Health & Social Care Joint Management Team
Programme
Management
Project/Task Groups
Finance and
Governance
Working Group
Commissioning
Development
ICE
Implementat
ion Group,
Dementia
Board,
Elderly/falls
Grp
Urgent
Care
Board
H&SC
Integration
Model of Care
Steering
Group
Primary Care
Development
GP network
Development groups
Annex 8 – Implementation Timescales
Jun-14
Jul-14
DRAFT ICE Implementation Milestones
Aug-14
Sep-14
Oct-14 Nov-14
Dec-14
Jan-15
Feb-15
Mar-15 2015/16
Operating Model
Phase 1 - planning
Phase 2 - planning
Medical Responsibility, up to 12 week support, Supported
Discharge, Enhanced Nursing (virtual ward), Interfaces
between services
Go Live
Communications
Governance
WSIC Model
Phase 1 Go Live
Phase 2 Go Live
Communications and Engagement with key stakeholders: Primary Care, Secondary Care, LAS, Social Services, voluntary sector
Patient/carers
Ealing Exec Ealing GB
ICE Implementation Steering Group . Reporting to
Monthly
Ealing Urgent Care Board
Report
Ealing Exec via
Urgent Care PID
via
Ealing Urgent Care Board
Integrate with Ealing
CCG broader Strategic
Developments WSIC
WISC
Contracting Process
Outline Plan
Pilot for Care Co-ordination & Navigation
submission
Implementation Phase - shared Management Team in place
Full Business Plan
Phase 1 - In yr variation 2014/15 agreed
Phase 2(2015/16): Commissioning Intentions/Contract Round
Performance
Phase 1: Performance - monthly monitoring
30