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Lesley Strong and Hazel Carpenter: integrating community and social care services in Kent

Date post:16-May-2015
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Lesley Strong and Hazel Carpenter discuss how Kent County Council, Kent and Medway NHS and Social Care Partnership Trust, Kent Community Health NHS Trust and the clinical commissioning groups have been working together to join up community health and social care services in the county. Components of integrated care include: a system of risk stratification to determine which high-risk patients the multidisciplinary team are going to work with; co-located, mobile and flexible teams; a single assessment process with assistive technology at the core; and health and social care co-ordinators appointed in some localities.
  • 1. Kent Health Economy Integrating Community and Social Care Service Lesley Strong, Kent Community Health Trust Hazel Carpenter, Accountable Officer South Kent Coast CCG

2. Localities South Kent Coast Thanet C4G Ashford Swale West Kent DGS 3. There are no gaps in my care I was always kept informed The team always talked to each other to get me the best care I always knew who was in charge of my care and who to contact I didnt have to keep repeating myself to lots of different people I didnt have to wait in all day for lots of different people to come at different times I was fully involved in the decisions and knew what was in my care plan There was a plan in place to help me cope if I thought things were getting worse and make sure I stayed at home and didnt have to go into hospital or long term care My GP knew who she was dealing with in the team What we want to achieve, so our clients say 4. Introducing HASCIP Care pathways first Focusing on function and how we make integration work at the front-line of our services - swiftly Not discounting structural integration, it is not our starting point Its about practical measures - by bringing our teams and systems together today Medium term - we may move towards greater unity, e.g. joint roles and appointments, joint accountabilities, joint training and pooling resources through developing concepts such as the trusted assessor. This approach allows us to remain agile and flexible, able to respond to the wider policy and commissioning landscape changes Our Vision for Integration: Tripartite Compact, KCC, KCHT, KMPT Making life-changing improvements to the experience and outcomes of people using health and social care services in Kent 5. Model 6. Implementation Implementation phase Nov 2011 to date CCGs began to share their commissioning intentions and engage in detailed discussions about the models of integration that would best support the needs of their local populations Single county wide one size fits all approach now is not appropriate Programme management was devolved from a county-wide, centralised approach to the locality led implementation groups aligned to the 7 CCGs HASCIP now driven by locality led implementation groups, underpinned by and delivering local Operational Frameworks 7. What is in place since the compact was agreed? Risk stratification for health and social care; we are beginning to see what the joint 5 % caseload is - challenge: what does that mean for the joint caseload, change in practice Co-located, mobile and flexible teams: CCG locality lead development multi-disciplinary teams Single assessment process and FACE documentation rolled out within teams and some acute providers; digital pens project; Trusted Assessors - challenge: information governance and IT solutions - challenge: how to implement integrated anticipatory care plans Health and social care co-ordinators appointed in some localities - challenge: will MDTs be able to use them to achieve LTC objectives Self care e.g. assistive technology at the core of single assessment and provision of care Pathfinder for 3 Million Lives , Industry providing a managed service. Health Trainers, Patient Knows Best 8. Key example Proactive care: 12 week intensive package of support. The foundation of the model is to place the individual at the centre of all decision making. Individuals and their carers and families are supported by a wrap around clinical team to become experts in their particular long-term condition. Dr Tuan Nguyen, Folkestone GP 9. Outcomes of proactive care 15% reduction in A&E attendances. 55% reduction in non elective admissions. 37% of the cohort has reduced admission risk score. Total saving to date 225,938. 75% patients reporting improvement in functional quality. Plus, 86% no longer anxious about condition from baseline of 46%. 10. Top tips to make it work GP clinical engagement from the outset is crucial. Risk stratification to identify appropriate patients requires a joint approach between the GP and matron. Administration support to manage the MDT meetings and communication links is essential. MDT reviews must be well planned and fully engage the patient and their families in the goal setting. Nursing caseload reviews need to be completed prior to roll out to ensure capacity is built into the system. 11. An ageing population with significant pockets of deprivation and rising inequalities 12. NHS South Kent Coast Clinical Commissioning Group To ensure the best health and care for our community ..which will be delivered through: Keeping the patient at the heart of everything we do Ensuring that all commissioning is led by clinicians Making the most of all the resources at every opportunity Keeping a strong focus on working closely with all of our partners Ensuring that services are as integrated as possible Keeping services as local as possible 13. We are NOT a PCT! Different scope of responsibilities Membership organisation Clinically led Duty and powers to collaborate and deliver integrated service models around the patient We need to realise: the impact clinicians can have on commissioning delivery and clinical outcomes of commissioning well; the potential patient benefits of integration and collaboration; the benefits of a membership 14. Commissioning context Opportunities 1. CCG values focus on: Integration whole population working with partners Distributive Clinical Leadership with whole member engagement 2. Pathfinder tier two Health and Wellbeing Board 3. GP evangelists for Patient Knows Best Telecare Pro-active care and risk stratification Challenges 1. Wave 4 CCG late in developing member focused governance impact on adoption 2. Historically under doctored with a variation a resulting inconsistent primary care model impact on spread 3. Modelling costs to inform investment at tipping point 4. Aligning incentives 15. 24/7 integrated single points of access: challenge to design, implement, fund and to make it work How to integrate mental health, secondary care services in primary and community services. Joint KPIs and performance management Client feedback and surveys, co-production to inform delivery Workforce: joint induction, training and development and opportunities to share good practice and innovate. Information governance and consent protocols Joint workplaces , IT and patient/client record systems Challenges

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