joined-up services: health and wellbeing board october 2013 engagement event presentation

Health and Wellbeing Board Engagement Event

Joined-Up Services31 October 2013

Jordanthorpe

Welcome and Introduction

Councillor Julie DoreCo-Chair of Sheffield’s Health and

Wellbeing Board

What have people told us is important about joined-up

services?

Joe Fowler, Director of Commissioning, Sheffield City Council

• Engagement Event – July 2013• Staff event – September 2013• Integration Advisory Group – October 2013

How we have engaged so far

• Leadership – we need to know who is leading the work and the vision, and how they are going to share this with others

• Commissioning – we need this to be integrated, and we need the way that things are commissioned to be transparent and co-producing with our customers

• Culture – our cultures and behaviours need to change on the frontline and in the back office

• Evidence-based – we need to know what has worked elsewhere and build on that

Key themes (1)

• Back-office – budgets, ICT, legal, etc. all need to be joined up

• Innovation – we need space for people to be creative and innovative

• Communication and involvement – we need to be communicating and involving in everything – internally and externally

• Policy – we need to be engaging with Government and others on this journey

Key themes (2)

Discussions around round tables

• What’s your experience of services in Sheffield?

• What do you hope to take away from this meeting?

The Lowedges, Batemoor and Jordanthorpe Project: an

introduction

Carmen CalvoHelen Chapman

Karen DaleLorraine JubbAlex Shilkoff

From Little Acorns…..Integrated community working in

Sheffield

Lowedges, Batemoor & Jordanthorpe

• Population 10,538

• 22% of all households are

made up of elderly people

reliant on state support.

• in the top 5% most deprived

areas in England.

The beginning…….• There was snow

• There were older vulnerable people with little or no support

• There were overworked community health staff

• GP’s with patients that had social care needs not covered by formal

support

• There were lots of unscheduled admissions

• Patients confused by the pathways into health and social care

• There was lots of talk of integrated working, Right First

Time, Total Place

And then…..

• Winter planning

• Risk stratification

• Development of Community Support Worker role

• Multi-agency meetings

A Combined Risk Stratification Model

Referrals in and out

Mr “Wolf”Referred by GP due to concerns over high number of

emergency admissions.

Family liaison

Community LD nurse

Supported Living

ASC

Mental Health Team

Mr W’s misuse of emergency services has been

considerably lower. He has not had any

admissions in the last 3 months .

The multi-agency approach has resulted in Mr

W being able to keep his independence and

maintain a good quality of life as well as

reducing costs to both health and social care.

By liaising with Sheffield Council Housing

and Amey the handrail has now been

replaced and Mrs P is back to leading an

independent happy life.

GP

Sheffield Council Housing

Amey

Mrs Prison 93yrs oldReferred by GP because depressed and anxious.

Until recently Mrs P had lived independently, done her

own shopping and participated in her local lunch club

but work in the local area had resulted in a handrail

near her home being removed, this resulted in Mrs P

becoming housebound overnight.

Before After

The Multi-Agency Team

Stories from the frontline

• Jenny Reed, Shelter• Bev Faye, Community Matron• Lesley Dawn, Social Worker• Marion Colohan, Practice Manager

Time for questions

Mrs “Brown”Is an independent, proud and intelligent

86yr old lady who lives alone in her own

home. Mrs Brown has a history of

declining any kind of help or support.

Discussions around round tables

• Do you identify with these experiences in the area you work?

• Do you have any best practice which you can share so the project can continue to improve?

The impact of and lessons learned from the project

Helen ChapmanLorraine Jubb

Impact

• Responsive services

• Appropriate use of available resources

• Reduced non-elective admissions

• A reduction in A&E attendances for over 65s in LBJ when the city

average had increased

• Increased individual and Community resilience

• Delay in people requiring support from ASC

• 8 Community Support Workers funded by the CCG

The Wider Impact

Data sharing

protocols

Housing Plus

Referral/pathways

Risk stratification

Transformation Modelling

Winter Planning

Community Support

Worker role

Market Dev &

Commissioning Plans

Job creation

Community Resilience

Virtual Ward

Integrated Care Planning

Local Economy

Community Nursing

It’s not just

about

Lowedges, B

atemoor and

Jordanthorpe

The Future

• Sharing learning across the city

• Exploring the possibility of developing a network

of people delivering the CSW role

• Development of links with VCF sector

• Putting the “front door” at the front

• Informing work of Local Area partnerships

• Enhancing monitoring and evaluation processes

Close

Thank you for comingPlease fill out a feedback form