towards improving community based services in cumbria: mrs
TRANSCRIPT
Gillian Mathews Deputy Director of Integration and Service Transformation
Towards improving community based services in Cumbria Mrs carlisle
and other stories
73.4 people per km2
921 people per km2
Pop 500,000
Mental health and community services
The story of Mrs Carlisle
Cumbria Projected Population >65
Percentage of the population of England and Cumbria aged 65 years and over: 2004 to 2029
10
12
14
16
18
20
22
24
26
28
30
2004 2009 2014 2019 2024 2029Year
% p
opul
atio
n
England Cumbria
Cumbria 65+ Population: selected health projections (numbers people)
0
5,000
10,000
15,000
20,000
25,000
2008 2010 2015 2020 2025
Year
Numb
er of
peop
le
Unable to manage at leastone mobility activity
75+ registerd blind or partiallysighted
Dementia
LTLI caused by heart attack
Falls (A&E attendance)
Severe depression (lowestestimate level)
LTLI caused by stroke
Falls (hospital admission)
Older and more frail
– The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions
– More people have 2 or more conditions than only have 1
Multimorbidity
Meet the Copelands…
We also know the Allerdales, the Carlisles, the Edens, the Furnesses and the Kendals
The story of our
communities
Why does integration matter to a provider trust?
• Better care for patients, especially those with complex and multiple needs
• Closer relationships with GPs – our key customers - and now our commissioners
• Better working with other partners – acute, social care, third sector
• More efficient use of our resources – specialists, front line staff, managers, systems
• Consistent with commissioning intentions – care closer to home, reduced acute admissions, a new approach to long term conditions
Primary Healthcare Communities
GP GP GP GP GP GP GP GP GP GP GP GP GP
Com
mun
ity s
ervi
ces
Men
tal h
ealth
ser
vice
s Community team
manager
Community team
manager
Community team manager
Community team manager
County wide residential specialist services (e.g. Psych ITU, specialist EoL etc)
County wide community based specialist services (e.g. complex MH, diabetes)
Com
mun
ity s
ervi
ces
Men
tal h
ealth
ser
vice
s
Com
mun
ity s
ervi
ces
Men
tal h
ealth
ser
vice
s
Com
mun
ity s
ervi
ces
Men
tal h
ealth
ser
vice
s
Prim
ary
Hea
lthca
re C
omm
uniti
es
Specialist services
Social care Third sector
Social care
Third sector
Social care
Third sector
Social care Third sector
Community team coordinators
Primary healthcare communities
Services will be delivered in
Primary Healthcare
Communities wherever it is
safe and practical to do
so
…probably!
Asset Based Approaches
• Focus on the capacity and skills of a community rather than problems deficits and needs
• Indentify and map the community assets
• Work with and through these assets
• Create connected communities
Cockermouth 20 November 2009
The story of our assets
A glass half full…*
“Communities have never been built upon their deficiencies. Building
communities has always depended on
mobilising the capacity and assets of people and
place.” Kretzman & McKnight (1993) Building Communities from the Inside Out
*A glass half-full: how an asset approach can improve community health and well-being. IDeA.
5 steps to integrated care
1. Use the patient’s perspective as the organising principle
2. Build an integrated multi-disciplinary team around the patient
3. Support the place based team with more specialist skills/teams
4. Manage care across a pathway
5. Deliver the benefits
To be continued…
Thank you! www.cumbriapartnership.nhs.uk Scottish primary care multimorbidity study A glass half full Centre for the third age, Cockermouth [email protected]