Transcript Slide 1

Health & Social Care Integration
Potential, problems & positives
and the role of IM&T
Geoff Lake
NEL Care Trust Plus
Part 1 - Context
The Facts About NEL
Organisational Journeys
The Care Trust Approach
The Facts About NEL
National Comparisons
North East Lincs
England
6.6%
5.5%
£453.50
£500.00
11.2%
4.8%
Household burglary rate per
10,000 households
204
128
Percentage of children in low
income households
51%
40%
Number of pupils gaining 5 or
more GCSE
53%
60.4%
Unemployment rate
Average weekly earnings (male)
Percentage of private households
deemed unfit for habitation
aa
aa
The Facts About NEL
Deprivation
49th most deprived out of the 354 Local Authorities in England (2007)
24% of lower level super output areas (LSOAs) in North East
Lincolnshire are amongst the most deprived 10% in England
49% of LSOAs in North East Lincolnshire are amongst the most
deprived 30% in England
The Facts About NEL
The people
Population – 158,400 (ONS estimates for 2007)
Forecast to increase by 12.21% by 2031 (from 158,900 in 2006
to 178,000 in 2031)
Greatest reduction – 15-19 age group (-11.76%)
Greatest increase – 85+ age group (+126.47%)
95.53% ‘White British’
The Facts About NEL
Health Impact
Male life expectancy 75.9 years (below national & regional average)
Female life expectancy 80.8 years (below national & regional average)
Biggest contributors to life expectancy gap:
- circulatory diseases
- cancers
- external causes
High teenage pregnancy rates
Smoking prevalence 33%
Third worst area in England for alcohol abuse
Childhood obesity
Organisational Journeys
NHS
PCG to PCT: Continuity
Clinical and managerial leadership
High performer / Innovation
Investment in partnership architecture
View of ‘single’ economy best served by integration
Organisational Journeys
North East Lincs Council
‘Humberside’ demise
‘0’ stars
Difficult transition, particularly operationally
Intervention
Loss of Chief Executive
Recovery to 1 star and ‘monitoring’ form of intervention whilst
building partnership
The Care Trust Plus Proposal
The design concept
Four Commissioning Groups led by front line staff and key stakeholders
– the engine room for self directed, integrated care
Creating a membership organisation with strong community links
Building a healthy community through increased choice, increased
control and moving from engagement to co-production
Our contribution to wider economic and social regeneration an important
element of our community leadership role
Only at the start of a significant journey
Part 2 – Policy and design
Personalisation
Transformation & Intervention model
Transforming Care plan
NEL Whole system model
Integrated Single Point of Access
Policy Drivers
Putting People First
Personalisation and linked themes
Intervention Model
Making the links for transformation
( Acknowledgement Nick Marcangelo CSIP CAT )
Example interventions
Population ‘needs’
Citizenship
General
population
Home and community
Information
• Involvement of older people
• Tackling ageism – positive images
• Equal access to mainstream services
• Making a positive contribution, including volunteering
• Community safety initiatives, including distraction burglary
• Locality based community development
• “No door the wrong door”
• Single point of access, self assessment, peer ‘navigators’
Low to
moderate
needs
Lifestyle
Practical support
Substantial
needs
• Befriending and counselling
• Shopping, gardening etc
• Case finding and case management of those at risk
Early intervention
Enablement
Community support for LTC
Complex
needs
• Active ageing initiatives
• Public health messages, including diet and smoking
• Peer health mentoring
• Intermediate care services
• Enablement services – developed from home care
• Integrated or co-located teams and/or networks
• Generic workers
• Case finding and case management of complex cases / LTC
Institutional avoidance
Timely discharge
• end of life care – enabling people to die at home
• Management of unscheduled care
• Hospital in-reach and step down pathways
• Post discharge support, settling in and proactive phone contact
Choice & Control:
Dignity:
Carers:
- people receiving self directed support, including direct payments and individual budgets
- Dignity challenge and ‘champions’
- carers receiving assessment, specific carers services, information, Expert Carers Programme
Transforming Care
Personalisation
( choice & control )
Strategic
Objectives
Community & provider
option “shaping”
Measurable
Outcomes
Numbers using
self-directed support
Year 2
Navigation skills
Support accessible
Equity of information
available for self-funders
User Led
Organisation
development
Personal Health
Budget learning
Development of
Support Planning
Options
Integrated
Organisation
Integrated Information available from
AIMs & other defined outlets
Seamless patient transits
Influencing
shape of market
Information and update
process development
Integrated care
system re-design
SAQ/RAS/IB
learning
Year 1
Enablers
Streetfront
Presence
High Quality
Provider Market
Positive experience
measures
Process Change
Integrated Information
Accessibility
Peer support options
available ( via AIMS )
Information strategy
definition
Efficient/value for money
Integrated measures
Workforce development
& OD initiatives
Practitioner efficiencies through
improved information sharing
Transformation
Grant
Integrated
frontline
delivery
Integrated Care Record
Approach & development & deployment
Planning
Leadership
NEL CAF definition
Corporate commitment
Stakeholder
Engagement
Establish platform for change
Integrated Information
Set in context of AIMS
Intermediate Tier &
Complex case Managemen
re-design
sharing Requirements
Transformation
Coordination
experienced
Reduced duplication
of info gathering
Exploit the Transformation
NEL Whole System Model
Tier 1
Tier 2
Tier 3
Home
Home or short
intervention
Home
Low level interventions
Early Intervention
Prevention
Rapid response
Safeguarding
Reablement
Refer
Participate
5%
Home care
providers
Information
ULOs
GP
Volunteers
3rd Sector
‘Social Capital’
Complex interventions
Needs driven
Intensive case
management
Long Term
care
Prevention
Self
Information
Tier 4
Care
Navigators
Home care
providers
Specialist
providers
A3
Intermediate
Tier
Community
nursing
CCM
Brokerage
Long Term
Care
Single Point of Access Model
Acute Discharge
Community Nursing
GP & Other Agencies
Professional contact via telephone
– xxxxxx
24/7
Self/Family/Carer
Self/Family/Carer
Public first contact via telephone –
629100
8am – 6pm
10 am – 4 pm w/e
Public first contact via Shop front
9 am – 5pm
10 am – 4 pm w/e
A3
Admin Answering
( A3 daytime / Provider OOH )
Assessment/triage
( telephone )
Rapid Response
( hands on )
Safeguarding
OOH
Provider – Intermediate Tier
Advice Officers
Duty Officers
Part 3 - Integrated Delivery & IM&T
Integrated Delivery
Strategic approach to adopt a single
System/record for Primary Care and
Adult Social Care
Integrated Delivery
Common Assessment Framework
Require a “Do Once and Share” approach to
demographics and assessment as
individuals move through the care system
Requires processes that;
-Ensure person centred (self) assessment
-Ensure proportionate assessment
-Effectively identify those who would benefit
from more in-depth assessment
Requires trust in information
And
Requires a means to share an evolving record
– the Shared Care Record in NEL
Integrated Delivery
Ambition for a broader approach to shared information
Examples of learning models:
To enable effective tracking of Continuing Care
IMCA/DOLS determinations
To enable effective alerting re risks to person/staff
To support coordination by providing an view of who
is involved and how to contact them
Potential ( with other initiatives ) to alert complex case
managers of unscheduled admissions
To enable the delivery and maintenance of Integrated care
plans and Person Held Records
To be the focus for collaboration on preventative strategies
Integrated Delivery
Supporting Personalisation in a shared record
Two key elements:
To enable management of a de-coupled Self Directed
Support process where control points are vital.
Assessment, planning/provision may be external to
CTP
To support the management of the allocation of
individual care budgets and future integrated care
budgets through Personal Health Budget
development
Integrated Delivery
Supporting Management in a shared record
Three Performance elements:
Delivering statutory Performance indicators
Supporting the emergence of health specific and integrated
team management performance indicators
To support the recording of overall benefits realisation
information to demonstrate delivery of the strategic Quality and
Efficiency premiums
Part 4 – Challenges
Making sure the programme delivers the Quality and Efficiency premiums
Establishing a shared record concept with the flexibility to learn and shape
with our staff
Governance ( access/sharing/consents/audit ). Meeting Care Record
Guarantees in an integrated approach
Performance – statutory and integrated team measures
Systems transition
Developing information links with partners outside of the single system
Part 5 – Growth of internet use
Web based Brokerage Tools:
– “same as me” knowledge base for self-directed support planning
Web based Provider registers:
– Personal Assistant/volunteer networks
Web based data from remote assessment tools:
– Telehealth and home activity monitors