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Integrated Care: Integrated Community Services
for AdultsCath Doman
Head of Community Health CommissioningProgramme Lead Integrated CareNHS Airedale, Bradford and Leeds
Lyn SowrayAssistant Director
Adult and Community ServicesBradford Metropolitan District Council
Integrated care programme
• Delivering the vision for integration
• Transformation of health + social care in the District
• Integration of community services clustered around GP practice/s
• Services working as a single team for each locality
• Risk stratification of locality population
…whatever the person needs following (or to prevent) acute care or long-term dependence
• Reablement• Rehab• Recuperation• Return to optimal health + wellbeing
In simple terms, it’s…
The vision
Right careright placefirst time
Joined up services to enable people to regain and keep their optimal health, well-
being and independence
The health economy• Need for new models of care delivery
– Funding gap– Shift from hospital to community requires greater
capacity and productivity in community services– Growing demand/population requires a preventative
approach– Increased capacity to prevent needs escalating– Better case management across partners to reduce
bureaucracy, duplication, riskAdapted from slide by Nick Morris BDCT
The PartnersCommissioners• NHS Airedale, Bradford and Leeds• Emerging Clinical Commissioning Groups• BMDC• NYCC (for Craven)
Providers• Bradford District Care Trust• Bradford Teaching Hospitals• Airedale NHS FT• Bradford Metropolitan Borough Council• Voluntary and Community Sector• North Yorkshire County Council
Integrated functions• Community nursing
• Intermediate care services
• Community therapy services
• Long-term conditions management
• Long-term support and care
• Rehabilitation and reablement
• Associated support services - VCS
• Opportunities to include MH + LD services
The programmeAccess Assessment,
diagnosis + care planning
Community beds
Home-based support Falls and bone health Long-term conditions
Estates IT Performance
Assistive technology VCS Communications
HR + OD Finance Risk stratification
Mental health and dementia
En
able
Scale of Step Up Intermediate Care
Principle: Care close to home
Maximise care at home.Minimise need for hospitalisation.
Dr Tom Downes 2008
Timescale: 2-3 years
• 2011/12 Transfer + achieve consensusTransfer of community services and development of strategy
• 2012/13 ChangeEarly wins: test-sites across District of teams working together, common criteria, assessment and records, enablement working alongside therapy and community nursing
• 2013/14 Polish + make it stick111, pooled budged, single management, health + social care services delivered from community-based hubs
Practices putting in proposals
now
Introducing Mrs Jones…
District
nurse
GP
OT
podiatrist
Out-patient
s
Social worke
r
Social services OT
Physio
Practice nurse
Home care Heart
doc Diabetes doc
Warden
BDCT BMDC InCommunities BTHFT VCSANHSFT GP
Discharge team
Equipment services
CMHT
Housinggrants
MATS
Community Matron
Discussion and questions