From Gaun Yersel to Older and Better

Anne Hendry

National Clinical Lead for Quality

JIT Associate

7 steps for changing the world

• A compelling vision• A story• Actions / Stepping stones• Securing the improvement• Engaging the workforce• Making the change work locally (everywhere)• Resilience, authorisation and a guiding coalition

Cocreating our Vision

Throughout Scotland, people with long term conditions and those who support them, feel valued, confident and enjoy full and positive lives

Culture of Quality and Ambition Collaboration, capacity & capability

Self Management

7 High Impact Changes

High Level Outcome Statements Bundles of Improvement Actions

Partnership We empower people living with long term conditions, their carers and the voluntary sector to be full partners in planning, improving quality and enhancing the experience of care.

Mutuality

Self Management

WorkforceDevelopment

Integrated Care

We support people with long term conditions and their unpaid carers to be involved in person-centred care planning.

We commission self management support for people with long term conditions and their carers and provide relevant, accessible information

We train staff to have the right knowledge, skills and approach to long term conditions care.

We provide better, local and faster access to healthcare, social care and housing services for long term conditions

Quality ImprovementWe strengthen the contribution of Managed Clinical/Care Networks (MCNs) in improving support for people with long term conditions

Clinical Information SystemsWe have information systems that support registration, recall and review of people with multiple conditions, and support data sharing across all partners.

Implementation & Improvement Support • LTC Programme Board – governance and key

strategic partners eg NES; LTCAS; NHS 24

• Delivery group – Operational exec and clinical leaders witrh a focus on performance

• LTC Collaborative - local programme teams with a focus on improvement

• Engagement – LTC are everyone’s business

Improvement Activists• Visible leaders across professions • Influential at all levels and across system • Leverage in professional structures • Influence on corporate focus• Influential in workforce planning • Lead roles in practice development

• Users and carers

2 Million Lives : people not patients

Digital Story Library

Top Tips and Practical Guidance

Spread and Adoption

Buddying, Networking and Practice Exchange

Sutor Ward Invergordon

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Aug-06 Feb-07 Aug-07 Feb-08 Aug-08 Feb-09 Aug-09 Feb-10 Aug-10 Feb-11

LOS Discharges

Extended Community

Team Meetings

+

Spot Purchase Home Care

Food for Thought ……. Using Local Improvement Data

Driving National Performance Bed Days per 100,000 population for T6 Long Term Conditions

Monthly Trend

0

100

200

300

400

500

600

700

800

900

1,000

Month of Discharge

Mo

nth

ly B

ed

Da

ys

pe

r 1

00

K p

op

Scotland 12 month moving Average Scotland 12 month moving Average Scotland Monthly T6 Bed Days

Scotland Trajectory Target Scotland Trajectory Target Linear (Scotland Trajectory Target)

LTCC launch High Impact

Changes and support

15% reduction in bed day rate

The Next Challenge Reshaping Care

Reshaping Care for Older People

‘Older people in Scotland are valued as an asset, their voices are heard, and older people are supported to

enjoy full and positive lives in their own home or in a homely setting.’

Implementation & Improvement • Shared Vision – An Older and Better Scotland

• 3 workstreams – co-production and community capacity building; housing and care settings; care pathways

• Change Fund as catalyst to lever change in spend

• Local Change Plans agreed by NHS, council, third sector and independent sector partners and agreed Joint Commissioning plans by 2012 / 13

• Improvement network and support from JIT

• Core set of measures of success

Reshaping Care Pathway

Integrated Community Team

NHS Lothian

3000

3500

4000

4500

5000

5500

6000

6500

Mar-09

May-09Jul-0

9Sep-09

Nov-09Jan-10

Mar-10

May-10Jul-1

0Sep-10

Nov-10Jan-11

Mar-11

May-11Jul-1

1Sep-11

Nov-11Jan-12

Mar-12

An

nu

al B

ed D

ays

per

1,0

00 P

op

ula

tio

n

Area Rates of All Emergency Admission Bed Days Scotland Rates of All Emergency Admission Bed Days

Area Trajectory Target Scotland Trajectory Target

Area Trajectory Baseline / Milestone Scotland Trajectory Baseline / Milestone

Area Linear Trajectory Scotland Linear Trajectory

Management information only. Not for onward distribution.

75+ emergency bed days

Expected trend in emergency bed use (65+) at 2006/07 rates ( P Knight)

6000

6500

7000

7500

8000

8500

9000

year

occu

pied

bed

s pa

tient

s ag

ed 6

5+

Year to 30 Sept 10 (prov)

Actual bed use

Expected at 2006 / 07 rates

Demand Management

~ 500 beds