Proactive Care Frameworks – Listen to our engagement and mobilisation phase talks

Two different approaches to implementing the UCLPartners Proactive Care Frameworks, shows how adaptable they are to meet local needs. Listen to the talks on SoundCloud and hear about the journey so far from colleagues in North Central London and North East London, two of the four pilots sites to implement the frameworks.

Summaries for each talk below:

North Central London – Integrated system centred approach
Amy Bowen, Director of System Improvement, North Central London CCG

• Single condition approach – made the decision to focus on hypertension and BP @home.
• Took the frameworks forward by using a Clinical Fellow model, by putting GP, Nurse and Clinical Pharmacist (Clinical) Fellow in four PCNs, which were tasked with getting BP@ home running in their patch.
• Combining the long term condition programme into a proactive care approach, joining both together. Regular meetings with UCLPartners, working to a common agenda. “Looking at elements of the framework and think how they might connect with, support, and sensibly embed into our approach to long term conditions.”
• Taken a system centred approach – gradually integrated all the different elements into NCL local approach.
• Stratification – NCL built searches into HealtheIntent, aim to build them into their population health management platform.
• Healthcare assistants scripts and protocols – holistic, personalised care and support built on a recognition that many people live with multi morbidity.
• Pathways – reflected into the way NCL have developed a model of care and the way they are approaching outcomes.
• Digital – Actively working to understand remote monitoring and virtual care across the whole ICS and how they link all the elements together in a coherent vision.
• Project Management – Worked very closely with UCLP and the long term conditions leads with weekly meetings.

North East London – Pan borough approach
Ken Aswani, GP and Long Term Conditions Lead, North East London CCG
Wayne Douglas, Senior Transformation Manager, North East London CCG

NEL had the highest prevalence for cardiovascular disease in London and also nationally, so there is a huge potential for improvement.

• Local approach – very much focused on how they support their PCNs. Developed a Community of Practice approach to share learning. Built up an infrastructure to make it happen in practice – this is where most of their learning has been. Particularly with PCNs having so many priorities, nevertheless, PCNs are engaged.
• Focused on hypertension and linked in with BP @home. NEL didn’t want to roll out all of the conditions in one go. They worked through key aspiration outcomes around hypertension.
• Started with 10 pilot PCN sites all focused on hypertension by choice – this has also led to more interest for further PCNs. Trying to embed this into their local incentive schemes – supplementary network services, by embedding this new way of working and linking it back to the long term condition reviews that are already happening in their boroughs and GP practices.
• Longer term goal – roll out across NEL and improve population health outcomes, focusing on how we make it real and make it happen. PCNs are learning from each other and embedding quality improvement and remote digital aspects.
• Co-morbidity and removing risk overall is the key ambition. Tools are very positive, tried and tested which makes it easier in the way them embed.
• Project management – UCLPartners were an integral part of the NEL team.

Further information on the Proactive Care Frameworks and how they can help primary care teams manage patients with cardiovascular and respiratory long-term conditions can be found here: https://uclpartners.com/proactive-care/