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Health & Social Care Integration
Potential, problems & positivesand the role of IM&T
Geoff LakeNEL Care Trust Plus
Part 1 - Context
The Facts About NEL
Organisational Journeys
The Care Trust Approach
The Facts About NEL
North East Lincs England
Unemployment rate 6.6% 5.5%
Average weekly earnings (male) £453.50 £500.00
Percentage of private households deemed unfit for habitation
11.2% 4.8%
Household burglary rate per 10,000 householdsaa
204 128
Percentage of children in low income householdsaa
51% 40%
Number of pupils gaining 5 or more GCSE
53% 60.4%
National Comparisons
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
Deprivation
The Facts About NEL
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 people
The Facts About NEL
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
Health Impact
The Facts About NEL
Organisational Journeys
PCG to PCT: Continuity
Clinical and managerial leadership
High performer / Innovation
Investment in partnership architecture
View of ‘single’ economy best served by integration
NHS
Organisational Journeys
‘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
North East Lincs Council
The Care Trust Plus Proposal
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
The design concept
Part 2 – Policy and design
Personalisation
Transformation & Intervention model
Transforming Care plan
NEL Whole system model
Integrated Single Point of Access
Policy DriversPutting People First
Personalisation and linked themes
Low to moderate
needs
Citizenship
Information
Lifestyle
Practical support
Early intervention
Enablement
Community support for LTC
Institutional avoidance
Timely discharge
General population
Complex needs
Substantial needs
• Involvement of older people• Tackling ageism – positive images• Equal access to mainstream services• Making a positive contribution, including volunteering
• “No door the wrong door”• Single point of access, self assessment, peer ‘navigators’
• Active ageing initiatives• Public health messages, including diet and smoking• Peer health mentoring
• Befriending and counselling• Shopping, gardening etc• Case finding and case management of those at risk
• Intermediate care services• Enablement services – developed from home care
• Hospital in-reach and step down pathways• Post discharge support, settling in and proactive phone contact
• Integrated or co-located teams and/or networks• Generic workers• Case finding and case management of complex cases / LTC
• end of life care – enabling people to die at home• Management of unscheduled care
Choice & Control: - people receiving self directed support, including direct payments and individual budgetsDignity: - Dignity challenge and ‘champions’Carers: - carers receiving assessment, specific carers services, information, Expert Carers Programme
Home and community • Community safety initiatives, including distraction burglary• Locality based community development
Population ‘needs’ Example interventions
Intervention ModelMaking the links for transformation ( Acknowledgement Nick Marcangelo CSIP CAT )
Enablers
Process Change
MeasurableOutcomes
Strategic Objectives
Establish platform for change Transformation Exploit the Transformation
Ye
ar
1Y
ea
r 2
Community & provider option “shaping”
Integrated Organisation
Integrated Information Accessibility
Integrated frontline delivery
Personalisation ( choice & control )
Planning
StakeholderEngagement
Leadership
Numbers using self-directed support
Positive experience measures
SAQ/RAS/IB learning
Personal HealthBudget learning
Development of Support Planning
Options
Corporate commitment
Transformation Grant
Integrated Care RecordApproach & development & deployment
Integrated Information
sharing Requirements
NEL CAF definition
Reduced duplication of info gathering
Set in context of AIMSIntermediate Tier &
Complex case Managemenre-design
Coordination experienced
Practitioner efficiencies through improved information sharing
Navigation skillsSupport accessible
Peer support options available ( via AIMS )
High Quality Provider Market
User Led Organisation development
Influencing shape of market
Equity of information available for self-funders
StreetfrontPresence
Integrated Information available from AIMs & other defined outlets
Information strategy definition
Information and update process development
Seamless patient transits
Workforce development& OD initiatives
Integrated care system re-design
Efficient/value for moneyIntegrated measures
Transforming Care
NEL Whole System Model
Specialist providers
GP
Tier 1
Home
Low level interventions
Early InterventionPrevention
Participate
Long Term Care
CCMIntermediate Tier
Community nursing
A3
‘Social Capital’
Volunteers
Information
Refer
Brokerage
Care Navigators
Home care providers
Home care providersInformation
5%
Tier 2
Home or short intervention
Rapid responseSafeguardingReablement
Tier 3
Home
Complex interventionsNeeds drivenIntensive casemanagement
Prevention
Tier 4
Long Term care
3rd Sector
ULOs
Self
Single Point of Access Model
Public first contact via Shop front 9 am – 5pm
10 am – 4 pm w/e
Public first contact via telephone – 629100
8am – 6pm10 am – 4 pm w/e
Professional contact via telephone – xxxxxx
24/7
Advice Officers
Admin Answering( A3 daytime / Provider OOH )
Assessment/triage( telephone )
Acute DischargeCommunity NursingGP & Other Agencies Self/Family/Carer Self/Family/Carer
A3
Rapid Response( hands on )
Duty Officers
OOH
Safeguarding
Provider – Intermediate Tier
Part 3 - Integrated Delivery & IM&T
Integrated Delivery
Strategic approach to adopt a singleSystem/record for Primary Care andAdult Social Care
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
Common Assessment Framework
Integrated Delivery
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
Ambition for a broader approach to shared information
Integrated Delivery
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
Supporting Personalisation in a shared record
Integrated Delivery
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
Supporting Management in a shared record
Integrated Delivery
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