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