making integration work - sandra birnie and will ivatt
TRANSCRIPT
Delivering Integrated Health and Social Care in West Cheshire: A work in progress
Our context
• People are living longer, and although this is something to celebrate it also places additional pressure on health, social care and housing.
• Over the past five years, an 18% rise the number of people over the age of 85 has resulted in a 40% increase in the number of unplanned hospital admissions, and a 30% rise in unplanned hospital bed days
• Locally, £167m is spent on NHS acute and community care and social care on the over 65s
• At the same time, Local Government is making budget reductions of 25+% and the NHS is on ‘flat cash’ at a time when demand for acute care continues to increase
• Using current demographic forecasts it is estimated that if we were to maintain existing service delivery mechanisms, we would require an additional £19.1 million
• Partners across Cheshire have agreed to work together to meet these challenges
• We will initially focus on people aged 65+ who live in Cheshire West who need care and support or who are at risk
• Specifically, the intention is to reduce non-elective bed day use by those aged over 65 by 25-30%, accompanied by a 15% reduction of placements into long term care with an initial focus on people aged 85+
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92.0%
1.1%
0.7%
6.2%
At home without formal support
In hospital
Rehab and Reablement
Receiving care at home
8.8% over 65 year old population cost the health and social care eco-
nomy £167 million
Understanding our population
Where are our over 65s?
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How is the £167 million spent?
45.00%
1.00%
32.34%
20.87%
0.57%
Keeping healthy in own place of residence
Presentation and assessment of condition
Diagnosis, treatment and care plan delivery
Return to normal place of residence
End of life care
Understanding our population
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When I needed support to live at home, services worked together to
provide it
When I went to a new service, they knew who I was, what my
circumstances were, and about my own views and preferences
When I was discharged from a service, there was a plan in place for what
happened next
When I used a new service, my care plan was known in advance and
respected
The information I was given was comprehensive: it was not just
medical, but also helped me understand the impact of my health
status on other parts of my life
I could see my health and care records at any time to check what was going
on
I had one first point of contact. They understood both me and my
condition. I could go to them with questions at any time
The professionals involved with me talked to each other. I could see that
they worked as a team
What our communities are telling us
My residential care provider maintained close links with the health and social care professionals and my
GP stayed actively involved in my care
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Translating this into our vision
Older people live life to the full in their communities and stay as fit and well as they can to the end of their lives and, if they need support, they can exercise real choice and control about the nature of that support.
Older people who need support will be enabled to live at home by integrated community services working in a holistic way that is proportionate to their needs. Older people will only be admitted to hospital and care homes if the exacerbation of their needs exceeds the capacity of what can be safely and at least cost delivered in the community. They should not be cared for in hospitals and care homes for longer than necessary.
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How this translates into a new model of care
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Community Service-led (in partnership)
COCH-led (in partnership)
Jointly-led
Shared enablers
the Care ModelKey elements of
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The new model at a glance: A Wider View
How the priority elements of the new care model are being delivered
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A single point of access and common assessment process for health and social care enabling better access to the right services, a common understanding of need across agencies, view people in a holistic way looking together at their physical and mental needs and further sharing of information.
Single Point
Of Access
The new care model
Stronger Communities
A new approach to encourage stronger communities which treats older adults as assets and enables communities to help themselves where possible.
A more coherent approach to self-care, maximising the potential of personalisation, shifting power and responsibility to citizens. Encourages individuals to pursue the 5 ways to Health and Wellbeing .
Self-Care
A number of integrated locality teams aligned to GP surgeries - bringing together health, social care, the voluntary and community sector, and other professionals- enabling joint management of cases and interventions across organisational boundaries
Inte
grat
ed
Team
s
The development of a shared care record across all health and social care partners in West Cheshire to support more efficient and effective working and enables the patient to be at the heart of joint decision making. Flexible and mobile working will be rolled-out to all staff and ICT will be put in place to support new processes within the care model.
Enabling the care model
Resources will be shared across all partners in managing the programme of work and ongoing service delivery. Asset strategies will be joined to enable staff to work together in an integrated manner, no matter where they were previously based.
Shared systems and ICT
Shared
infrastructure
A new joint workforce development strategy will be in place to support our staff to develop, learn and co-produce the new care model and new ways of working. Leadership and culture change are key elements incorporated into this and programme governance will reflect staff, user and partner involvement.Jo
int W
orkf
orce
Develo
pmen
t
A new funding and contractual model which provides the right incentives to have a model of care which shifts activity and resources from inappropriate acute setting towards community-based care.
Funding and Contracting Model
Single Point of Access and Integrated Teams
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Single Point of Access: The Model Single Point
Of Access
Health and Social Care Call Handlers
Nurse and Social Care Coordinators
West Cheshire Gateway Service – 24/7 response
Call Streaming
Front of House Call Management
Call Triage
Discharge Management
Admissions Management Urgent Response
Referral Management/routine
response
Outcome
• Step down bed• Home-based
Intermediate Care• Community Services• Reablement• Residential Care
• Admit to acute care
• Step up bed
• Whole system communications
• Assessment
• Maintain at home
• Admission to MAU
• Step up bed
• Referral accepted
• Appointment allocated
Service response.
Single Point
Of Access
Single Point of Access: How it will work
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2013 2014 2015 2016
Scale Up Local Interventions
Develop Sustainable Whole-System Model Implementation of Whole-System Model
Single Point
Of Access
• Teams and activities identified
• ‘As-is’ process mapping• Demand analysis• Performance analysis• Functional analysis• ‘To-be’ processes• Staffing alignment
• Extend to 8am-8pm• Infrastructural
changes• Staff re-location• ICT and system
alignment
• Assess progress• Update performance
framework
Defi
neD
esig
nD
eliv
erRe
fine
2017
Completed
On track / Ahead
Single Point of Access: Progress against the plan
Co-ordinated Points of Access
Inte
grat
ed
Team
s
Integrated Teams: The Model
Inte
grat
ed
Team
s
2013 2014 2015 2016
Scale Up Local Interventions
Develop Sustainable Whole-System Model Implementation of Whole-System Model
• Teams and activities identified
• Demand analysis• Functional analysis• Staffing alignment
• Team co-location• ICT and system alignment• Care Co-ordinators in post• MDT meetings in place• Team Go-Live:
• Princeway• Broxton• Tarporley• Lache• Northgate• Boughton• EP North• EP South• Neston
• Process alignment – assessment and referrals• Assess progress• Update performance
framework
Defi
neD
esig
nD
eliv
erRe
fine
2017
Completed
On track / Ahead
Integrated Teams: Progress against the plan
Team ‘Live’ and co-located
‘Virtual’ team in place
Scheduled to be ‘Live’ and co-located
Princeway Broxton Tarporley Lache Northgate Boughton Ellesmere Port South
Ellesmere Port North Neston
GP surgeries HelsbyFrodsham Medical The Knoll
MalpasTattenhallFarndon
BunburyTarporley x 2Kelsall
LacheCity WallsWestern AvenueHandbridge
Northgate VillageNorthgate MedicalThe ElmsHoole RoadGarden Lane
BoughtonParkHeath LaneUpton
Whitby x 3Old HallYork RoadWestminster
Great Sutton x 3Hope Farm
WillastonNeston MedicalNeston Surgery
Practice population
26,309 14,021 22,736 34,163 36,349 33,433 35,345 31,567 20,176
Population 65+ 5,593 3,093 5,327 7,017 4,778 6,195 5,601 5,703 5,014
Population 85+ 736 410 620 692 872 900 642 640 583
Process / Staff alignment
Team co-located Jan 2015 Jan 2015 March 2015
Care co-ordinator in place
MDT’s
Inte
grat
ed
Team
s
Progress at a glance…
Integrated Teams: Team composition and progress
Agree a shared vision Realistic timescales and expectations Funding Strong leadership Robust governance framework Engage key enablers esp. ICT and estates Joint project planning Relationships and ownership Co-location Integrated management
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Some learning
Developing a single outcomes framework to support all of this
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The outcomes framework: Key metrics Single Performance &
Outcomes Framework
Care Model Metrics
Care Model metrics with alignment to specific elements
Metrics specific to elements of the Care Model
Outcome
Type of Benefit
Method of Measurement Baseline
Performance Checkpoints
Quality Productivity Gain
Cost Avoidance
Cash Releasing 3 Months 6 Months 12 Months
Reduction in unplanned admissions aged 65-84 x
Number of bed days for patient cohort
by age
824 (monthly average)
Reduction in the number of older people, in our care, (aged 65-84) readmitted within 30 days of discharge from acute care
x number of
readmissions within 30 days
249 (monthly average)
Reduction in A&E attendances for high frequency users x
Number of admissions for this cohort of patients
TBC
Increase in user satisfaction x Survey TBC
Increase in staff satisfaction x x Survey TBC
Increase in GP satisfaction x x Survey TBC
Increase in the number of single assessments completed by the integrated team
x x x
Number of single assessments and number of uni-
professional assessments completed
TBC
The framework in development…
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Overseeing and driving delivery
West Cheshire Health & Wellbeing Board
Commissioning Delivery Committee
Joint Accountable Provider Board
Connecting Care Programme Board
Connecting Care Provider Board
Vale Royal CCG
Strategic Commissioning
DMT
CW&C
Pioneer Panel
CWP Ops Board
CWP
Integrated Community
Services Sub Group
COCH
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WCCCG
Self-Care Hospital Discharge
Integrated Teams (West)
Integrated Teams (VR)
Intermediate Care
(Reablement)
Stronger Communities
Front of House / SPA
