Delivering Better Outcomes Helping Older People to Help Themselves

Tony Homer Associate, Joint Improvement Team

Outcomes approach to community care

Outcomes FrameworkCommunity care users feeling safeUsers and carers satisfied with their involvement in the design of care packageUsers satisfied with opportunities for social interactionUser assessments completed to national standardCarers assessments completed to national standardCare plans reviewed within agreed timescaleShift in balance of care from institutional to home based carePeople 65+ with intensive needs receiving care at homePeople 65+ receiving personal care at homeEmergency bed days in acute specialties for people 65+People 65+ admitted as an emergency twice or more to acute specialtiesPeople 65+ admitted twice or more as an emergency who have not had an assessmentPatients waiting in short stay settings, or for more than 6 weeks elsewhere for discharge to appropriate settingPeople waiting longer than target for assessmentPeople waiting longer than target time for servicecarers who feel supported and capable to continue in their role as carer AccessCarersExperienceBalance of CareRisk of AdmissionQuality AssessmentOutcomes Framework

Outcomes approach to community care

Talking Points core concepts

Understand outcomes as the impact or end result of service(s) on a persons life

The user or carer is involved in identifying desired outcomes = setting goals in partnership with services

Partnership is key users, carers, services, other community resources to delivering outcomes

Quality of lifeProcessChange Feeling safe

Having things to do

Seeing people

As well as can be

Life as want (including where you live) Listened to

Having a say

Respect

Responded to

ReliabilityImproved confidence

Improved skills

Improved mobility

Reduced symptoms

Carer defined outcomes

Grappling with the Service Change Agenda

Cross-cutting policy prioritiesPersonalisation

Self Directed Support

Telehealthcare

Safety

Information systems

Service integration

Service ClustersCommunities and informal networks

Long term conditions

Crisis care and interim support

Housing and care options

Communities and informal careSupporting informal carers and volunteer networksCommunity capacity buildingBy:Better understanding the size, profile and needs of the informal carer populationTaking a non specialist perspective on what resources look like not overlooking universal public servicesInvolving all sections of the community so that they feel included and recognising that they have a contribution to makeInvesting in the potential of the current community

Communities and informal care South AyrshireCommunity development approach adopted across regeneration, health and childrens services. Now also incorporating Older Peoples servicesModel based upon Asset Based Communities approachFocussing upon Girvan, a small costal town/hinterland with regeneration funding and a new community hospitalCare home re-provisioning with ECH being plannedGIRFEC strategy included in developing agenda for change recognising everyones place in the community

Long Term ConditionsLong term care collaborative

Supporting better self care

Shifting investment upstream into anticipatory and preventative care

Telehealthcare

Using a re-ablement approach to re-skill and re-motivate users rather then create dependency

A Planned Approach to Patients at High Risk of Re-admission to Hospital Ayrshire & Arran

Use of SPARRA data to predict highest risk patients

Quarterly review of highest risk patients

Encourage use of self-management plans GPs and DNTs

Review of all emergency admissions A&E and Acute

Notification to NHS 24 and ADOC

Consideration of pulmonary rehabilitation

Crisis care and interim supportAvoiding unplanned hospital admissions and readmissionsAvoiding delayed hospital dischargesBy:Appropriate rapid response24/7 coverIntermediate care in a variety of settingsTelehealthcareRespite support for carers

Crisis Care Community based intermediate care service - Orkney

Accommodation and care optionsDemographic impacts and housingHousing quality and accessibilityOwner occupation and the social rented sectorCare HomesAspects of the way forward:Investment in normal housingPractical services to support householdersThe challenge of cross-tenure initiativesSpecialist housingNew roles for care homes

Accommodation and care options Scottish BordersSmall rural town with dispersed hinterland populationLong term care home for people with degenerative conditionsMove to tenanted flats with onsite care and support in communityRe-ablement and re-skilling approach reduced dependencySocial, activity and community engagement supportShift involved access to state benefits managing their own moneyGradual introduction of ILF applications/funding and shift of purchasing control to usersAdjustments to core provider budget and use of PAs

Things to rememberWhat would help us to help ourselves?Easy access to good informationChoice - real options that address your own circumstancesControl over deciding upon your preferred package / pathwaySelf managed or actively involved in service planning/delivery decisionsAble to decide what opportunities and potential risks are okay for youWithin a supportive process that is driven by what works for you

Picking up the change agenda outlined yesterday by Do Whoriskey, I want to look in a little more detail at how a focus upon outcomes in starting to make a difference at both a strategic and a personal level.The first important point to note is that it is this link between the strategic and the personal experiences of patients and users that will ultimately determine our ability to deliver services that provide the service that people want and need which in most cases is to be able to help themselves as much as possible.Key aspects of the process by which the strategic and the personal are linked, are:Putting individual outcomes at the heart of community care, by:Using assessment care plans and review to focus on outcomesGathering data from individual interactionsPresenting outcome data to managementInvesting to deliver personal outcomes

The key elements that an outcomes focus needs to be able to demonstrate it is impacting has been brought together in an Outcomes Framework.These are the key aspects of service that are important for users and carers and which present the greatest challenges to commissioners and service providers.*Achieving progress on the service issues highlighted in the outcomes framework is dependent upon related strategy/policy development, service re-design and commissioning.This diagram reflects the importance of there being a robust mechanism for capturing information about how far personal outcomes are being delivered, in order to be able to inform high level decision making. It reflects the application of the Talking Points tool which has been developed to facilitate face to face dialogue with users and carers in order to hear and better understand their views over the time that they are receiving care and support. This is the crucial link which we hope will enable statutory commissioners but also service providers to be better and more consistently informed about delivered services.**In essence Talking Points provides a consistent, academically rigorous and practically deliverable approach to obtaining user and carer views across different services and areas and also over the entire period that they receive a service.

It enables data to be collated and analysed across time and place in order that personal data is available directly to inform strategic decision-making. *It is based upon 2 sets of outcomes that emerged from the research as reflecting the outcomes that users and carers most want from the services they receive.*The change agenda that we need to address in order to improve outomes and help people to help themselves, can at times seem overwhelming. So many things need to change whilst we have to keep peddling the bicycle. The really important question though, is about the balance that is right for users and carers in a particular area, given its demographics, available resources and peoples wishes.It involves developing clinical and care pathways that may involve shifting location, shifting responsibility; shifting care and preventing or delaying more intensive and expensive interventions.It also involves listening to people and recognising the tremendous contribution that they and the wider community can make to finding local solutions that reflect the mutual interest that we all have in helping people to remain in their own home for as long as possible.I would like now to talk about the service changes that are beginning to take place across Scotland all of which are intended to deliver better outcomes and in so doing, support people to remain as independent as possible.Before I do however it is important to note the cross-cutting policy priorities that underpin service developments and reinforce their potential to deliver better outcomes Personalisation - providing services that deliver for the individual userSDS - enabling users to purchase and manage their health, personal and social careTelehealthcare - using technology to enhance the quality of careSafety- safeguarding those who are vulnerable or lack capacityInformation - single shared assessment, NMIS, TP, SPARRA(Scottish Patients At Risk of Readmission and Admission)Integration - governance, management delivery and workforce

In order to be able to focus in on the areas of service that are emerging as key to delivering the type of services that can help people to help themselves, I have clustered services and resources into 4 main areas. In each case I will describe a particular example of a change in service or approach that exemplifies the difference that can be made.I have placed communities and informal carers at the top of the list because in many ways this aspect of the resource agenda seems to me most likely to provide the key to establishing a sustainable balance between commissioned health and care services and the role of less formalised responses to peoples needs.The detail of what Im going to look at here reflects the changes in service models and approaches that seem most likely to deliver better outcomesWe know that in the very near future we and the politicians will have to ask ourselves what price we are prepared to pay for health and social care services and whether the present balance between what the state provides and what we as individuals choose to pay for or do for ourselves and others is sustainable. From a community perspective this dilemma raises important questions about what our potential collective contribution to helping our fellow citizens could look like, and how well equipped are we to rise to the challenge. Appreciative inquiry which identifies and analyses the community's past successes. This strengthens people's confidence in their own capacities and inspires them to take action The recognition of social capital and its importance as an asset. This is why ABCD focuses on the power of associations and informal linkages within the community, and the relationships built over time between community associations and external institutions Participatory approaches to development, which are based on principles of empowerment and ownership of the development process Community economic development models that place priority on collaborative efforts for economic development that makes best use of its own resource base Efforts to strengthen civil society. These efforts have focused on how to engage people as citizens (rather than clients) in development, and how to make local governance more effective and responsive To predict those patients (over 65) most at risk of emergency admission in the coming year. Lists are generated for front-line teams as a basis for further assessment to consider different approaches