Agenda item

At its last meeting the Board had considered the Proactive Management and Integrated Services for the Elderly (ProMISE) programme which used the JSNA as its basis and was a co-ordinated response to meeting the needs of a vulnerable group. The aim was for early intervention and prevention and to maintain healthy individuals by good management of diseases and better case management at an earlier stage.  At this meeting the Board had requested a further report giving more detail on the case management and integrated care.

Paul White, ProMISE Programme Director at Bromley CCG presented an update on these aspects of the programme.

St Christopher’s Hospice now had an enhanced “end of life” programme so that patients were able to die at their preferred place.  Within Bromley 60% of patients died in hospital compared to St Christopher’s where only 20% died in hospital. 

Case Management

39 GP practices had signed up to the programme and 18 were now referring to the programme.  Work was underway with patients and carers to try and reduce hospital admissions for this vulnerable group.

The majority of patients were over 65, with only 7 patients under 65.  There were also patients in the 90-100 year age group.  The ProMISE team had brought in an IT lead.  A lot of the data needed was in the practices and hopefully the team would be able to circumnavigate the current data access problems that were being experienced nationally.

Integrated Care

There was now a single point of entry to the integrated care model.  Six teams were working with GP practices and patients to ensure the correct package of care. The key was to build on this and expand the cover to other areas such as mental health.

The number of referrals to the service was low but this was a positive indicator that practices were trying to manage patients themselves. 

Although most GP practices were actively involved in care management, some needed encouragement to “buy in”.  In September 2013 a GP event has been arranged to promote self-care.

One Member raised concerns that some estates were not fit for purpose and that money would be spent on buildings not people.  In response, the Board was informed that work was underway to accommodate the teams but this would remain an issue until the future use of the Orpington hospital site was resolved. 

In response to a question asking what the Local Authority was doing to prevent hospital admissions of the elderly, the Executive Director Education, Care and Health Services explained that the Local Authority was a part of the assessment team offering patient assessments in their own homes.  The LA re-ablement service was one of the services that could be recommended to avoid hospital re-admissions but there were other providers giving input at different points. This included input from the voluntary sector.

It was agreed that an update would be presented to the Board at its November meeting to enable further discussion.

RESOLVED that:

1. the report be noted

2. A further report on the ProMISE programme would be submitted to the November Health and Wellbeing Board.