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