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What is Shifting the Balance of Care & How do we make change happen? Sylvia Wyatt [email protected] Three types of shift Shift in location Shift in responsibility Shift upstream Scope of SBC - 8 improvement areas 1. Maximise flexible & responsive care at home with carer support 2. Integrate health & social care and support for people in need 3. Reduce variation in unscheduled admissions 4. Improve capacity & flow for scheduled care 5. Extend the scope of services outside acute hospitals provided by non medical practitioners 6. Improve palliative and end of life care 7. Improve access to care for remote and rural populations 8. Improve joint use of resources SBC as an umbrella More care at home with carer support Integrated Reduce variation Capacity & flow Extend Better remote Health & In unscheduled for scheduled Services & rural care Social care admissions admissions outside hospital TeleLong term healthcare conditions Support for Changing Carer lives Home adaptations Personalisation A&E waits Local diagnostics 18 week RTT Care Pathway redesign Workforce use Equally well Better EOL & Palliative care EOL care Joint use of resources Electronic Records HUB CHI SBC supports health and wellbeing improvements National performance framework High impact Changes x48 SBC improvement Areas Single outcome agreements x8 HEAT targets Improve health & wellbeing SBC supports HEAT targets and SOA 8 SBC impact areas Shifts/improvements 1. Improve individual experience 2. 3. 4. 5. 6. Maximise flexible and responsive care at home, with support for carers Better integrated health and social care and support for people in need and at risk Reduce variation in unscheduled admissions to acute hospitals Improve capacity & flow for scheduled care Extend services outside hospital with non medical practitioners Improve access to care for remote and rural populations 7. Improve end of life care & palliative for all 8. Better joint use of resources Increased independence and personal choice Prevent/minimise adverse events Decrease institutional beddays National outcomes framework Single outcome agreements Make better use of non medical professionals Employ existing technology fully Reduce inequalities in time and geography Reduce infrastructure costs and carbon footprint HEAT targets 140 + things to do at once Maximise care at home with support for carers Reduce avoidable unscheduled events Better integrated health & social care. Improve capacity & flow better use non medical practitioners Remote and rural Improve EOL care Better joint use of resources Enhance unpaid carer capacity a Enhance unpaid carer capacity Enhance unpaid carer capacity Use tele-medicine & tele-health t Enhance unpaid carer capacity and support Enhance unpaid carer capacity a Enhance unpaid carer Single 24/7 point of contact f More investment into improvement in existing housing, More investment into improvement in existing housing, More investment into improvement in existing housing, Develop more near patient testing Use tele-care to provide 24/7 risk management, Use tele-care to provide 24/7 risk management, More investment into existing housing, Expand intermediate level services More extra care (new) houses More extra care (new) houses More extra care (new) houses Improve referral management by Use tele-medicine & tele-health to support care delivery Use tele-medicine & tele- More extra care (new) houses Better community transport Redesign home care services Use tele-care to provide 24/7 risk management, Redesign home care Understand and reduce variation in health and social care Multi-disciplinary extended community teams Anticipatory care and crisis prevention. Redesign home care services Voluntary sector organisations contributions Use tele-care to provide 24/7 risk management, Use tele-medicine & tele-health to support care delivery Use tele-care to provide 24/7 risk management, Redesign care pathways to optimise capacity Single 24/7 point of contact for local information and access to community services Multi-disciplinary extended community teams Use tele-care to provide 24/7 risk management, Continuity of information across organisational boundaries. Use tele-medicine & tele-health to support care delivery Anticipatory care and crisis prevention. Use tele-medicine & tele-health to support care delivery Reduce pre-operative beddays Overnight response for people in need Robust community emergency and urgent response systems Use tele-medicine & tele-health Align health and social care terms and conditions of service Self directed support Case manager or key worker to coordinate personalised care Self directed support Improve quality of health & social care Expand intermediate level services to provide alternatives to admission to acute hospitals Develop more near patient testing Self directed support Better management of age transitions More domiciliary assessment and rehabilitation Single 24/7 point of contact for local information Anticipatory care and crisis prevention. Change referral permissions so that people can self refer Robust community emergency and urgent response systems Better community transport More domiciliary assessment and rehabi Redesign care pathways to optimise capacity Anticipatory care and crisis prevention. Overnight response for people in need Case manager or key worker Screening, consultation & treatment by NMAP Develop more near patient testing Voluntary sector organisations contributions Anticipatory care and crisis prevention. single point of access Case manager or key worker to coordinate personalised care Expand intermediate level services to provide alternatives to admission Multi-disciplinary extended community teams including carers and users. Equitable funding for each CHP Integrated equipment library and adaptations service Mentoring, peer support/ expert patients to encourage self-care Case manager or key worker Develop community hospitals/local care centres/hubs Single 24/7 point of contact for local information Robust community emergency and urgent response systems Single 24/7 point of contact for local information Better medicines management by pharmacists Co location of services and teams across agencies Multi-disciplinary extended community teams Pool budgets between health and social care Overnight response for people in need Integrated equipment library Overnight response for people in need Redesign care pathways Improve referral management Overnight response Develop multi-skilled generic workers Develop more near patient testing Joint targeting of resources towards those people who are at risk Expand intermediate level services Improve quality and standardisation of routine health & social care through use of protocols Redesign care pathways to optimise capacity Expand intermediate level services Equitable funding for each CHP Integrated equipment library and adaptations service Voluntary sector organisations contributions Robust community emergency and urgent response systems Non medical prescribing within protocols for common conditions Electronic prescribing and postal dispensing Develop more near patient testing Self-held personal care plans/records Continuity of information. Better community transport Change referral permissions Mobile services Integrated equipment User participation in care planning Better medicines management by pharmacists Integrated equipment library and adaptations service Screening, consultation & treatment by non medical practitioners Obligate networks between remote and rural areas and larger centres User participation in care planning Joint targeting of resources towards those people who are at risk Understand and reduce variation in health and social care Self-held personal care plans/records Better access to psycho-social support Equitable funding for each CHP Voluntary sector organisations Voluntary sector organisations contributions Screening, consultation & treatment by non medical practitioners User participation in care planning Integrated services across health and social care with single point of access Continuity of information. Mentoring, peer support/ expert patients to encourage self-care Community based one stop shops/ ‘fast’ clinics Joint targeting of Community based one stop shops/ ‘fast’ clinics Increase clinical and social networks Better medicines management by pharmacists Mobile services to support community hospitals Voluntary sector organisations contributions Equitable funding for each CHP community including acute hospital costs Redesign care pathways to optimise capacity Redesign care pathways to optimise capacity Plan EOL care with family and carers with particular focus on last 48 hrs Continuity of information across organisational boundaries. Non medical prescribing within protocols Non medical prescribing within protocols for common conditions Develop community hospitals/local care centres/hubs Increase clinical and social network effectiveness Better access to psycho-social support Electronic prescribing and postal dispensing Equitable funding for each CHP Mentoring, peer support/ expert patients to encourage self-care Extend gold standard EOL care to everyone Plan EOL care with family and carers with particular focus on last 48 hrs Align health and social care terms and conditions of service Plan EOL care with family and carers Develop multi-skilled generic workers working across organisations Co location of services and teams across agencies Equitable funding for each CHP Equitable funding for each CHP Better management of age transitions Better medicines management by pharmacists Understand and reduce variation in health and social care Redesign care pathways to optimise capacity Improve quality of routine health & social care Non medical prescribing within protocols Better access to psycho-social support with single point of access Community based one stop shops/ ‘fast’ clinics Mobile services Plan EOL care with family and carers Develop community hospitals/local care centres/hubs Pool budgets between health and social care Develop multi-skilled generic SBC is complex Self Directed support Equitable Enhance carer funding support Co-location Better pharma care Intermediate care alternatives 24/7 local information Near patient testing Case management User participation Single point of access Improvement areas (8) Obligate networks One stop shops Fast clinics Protocols Community transport Existing housing adaptations Single point of Extended Comm teams Extra care housing Targeting resources Self referral Psycho-social Non medical support Tele-health prescribing Telecare Urgent care Domiciliary assess response & rehab redesign care pathways High impact changes access Understand variation Management of age transitions Extend role of NMAPs Redesigned home care Overnight Mentoring response Peer support Plan EOL Integrated equip Local care EOL library planning Referral Centres/hubs Self held management Voluntary records Home care Sector Network redesign Pool effectiveness Gold standard budgets Reduce preEOL Operative days Anticipatory care Continuity Mobile reducing crises of information services Innovative prescribing Generic workers More care at home with carer support Integrated health & social care Reduce variation in unscheduled admissions Capacity & flow for scheduled admissions Extend services outside hospital Better remote & rural care Better EOL& Palliative care Joint use of resources Single outcome agreements HEAT targets SBC changes are generic 1. Apply to health, social care, housing, and transport 2. Apply to several improvement areas 3. Are inter-dependent 4. Apply to any age group 5. Apply to any disease or dependency Implementing change Actions for communities • • • Describe baseline position in relation to 8 improvement areas Outline actions that will lead to measurable changes in locally selected areas of Improvement and Resource Framework Demonstrate clear line of sight into workforce development plans, eHealth and eCare strategies and infrastructure investment plans Suggested implementation process Prioritise 8 SBC improvement areas Measure baseline in priority areas Choose changes to address priorities Implement across whole CHP Measure SBC change across all 8 areas Prioritisation of 8 improvement areas SBC improvement area x8 Starting point High Impact Changes being prioritised 1.Maximise flexible & responsive care at home 2.Integrate health & social care and support for people in need 3.Reduce variation in unscheduled admissions Area to prioritise 4.Improve capacity & flow for scheduled care Area to prioritise 5.Extend the scope of services outside acute hospitals Area to prioritise 6.Improve palliative and end of life care 7.Improve access to care for remote and rural populations 8.Improve joint use of resources Overall position n/a Area to prioritise Local CHP/LA Measures Local CHP/LA Targets 2008/9 Evidence based SBC changes with greatest impac Enhance Rehabilitation informal carer and capacity reablement Community urgent response systems Voluntary Better sector pharmaceutic organisations al care Self referral Obligate networks Existing housing, equipment & adaptations Anticipatory care and crisis prevention Near patient testing electronic record and shared information Referral management Extra care houses Case manager Personalised care Community transport Clinical & Social Networks Understand and reduce variation Redesign home care Extended community teams Integrated equipment & adaptation service Mentoring & Single point peer support Redesign care Local care of access in dependent pathways centres / hubs care pathway people Telecare 24/7 risk management Single 24/7 point of contact Self-held personal care plans Reduce perioperative One stop shop beddays Integrated budgets Overnight Tele-medicine response for & tele-health people in need User participation in care planning Co location Quality & Innovative standardisatio prescribing & n of routine access to care medication Generic workers Intermediate level alternatives Resources aligned to care pathways Better management of transitions Self directed support Extending Improved non-med EOL and professional palliative care roles for all Psycho-social support Sylvia Wyatt SPACE lead for SBC Non medical prescribing Mobile services Plan EOL care with family and carers Aligned financial incentives Which of these....? • Addresses priority improvement areas •Fits with local population needs •Addresses inequalities •Improves patient experience Implement changes across whole system implement across whole partnership SBC Change Programme – possible criteria 1. Two + whole systems evidence based changes related to SBC Improvement Framework 2. Complete within 18 months 3. Robust plans for evaluating the process and measuring shifts in the balance of care 4. High level partnership involvement, bringing together other stands of work locally 5. Well articulated, operationalised new ways of working, shared information and/or joint use of resources 6. Commitment to disseminate what works and what does not work to shift the balance of care 7. Supports the delivery of HEAT targets and SOAs