Vanguard – Enhanced integration with care homes and social care.

Dr Dan Cowie Clinical Director Transformation

April 2015

NHS England Vanguard sites

• January 2015 NHS England invited organisations and partnerships to apply to become a Vanguard site for the new models of care programme including Enhanced heath in care homes

• This approach is seen as one of the first steps in delivering the NHSE Five Year Forward View through supporting improvement and integration of services

• More than 260 individual organisations and health and social care partnerships expressed an interest

• On the 10th March 2015 29 Vanguard sites were chosen

• Gateshead is one of only 6 enhanced health in care home sites

New Models of Care

• New ways of working:– Commissioning– Provision

• Accelerated LEARNING + IMPROVEMENT

• Working TOGETHER (design + delivery)– NG CCG + Gateshead LA– Stakeholders in SRG

• Establish a model – reciprocal across England

• Better Care, Better Health and Lower Cost– Leadership, relationships, large scale change– Embrace and believe it will work!

Gateshead - New Model

• Not about Care Homes (in isolation)• About health and Social Care integration• Cohort - Frailty spectrum• A new model for:

‘COMMUNITY BEDS and HOME-BASED CARE’

Setting the scene

• CARE HOME PROGRAMME – 206, 000 population– 9% increase in over people aged 85 years of

age by 2030– Over 1500 beds (community)– Started 2010– 9.3% reduction in non-elective admissions

(baseline 11/12)

Care-homes

Short-stay beds

Home-based care

RRR

Case Management

Twice weekly locality-based + community-based ward

rounds

Weekly locality-based ward rounds

+ Community-based MDT

Case/disease management/self care/promoting independence

Case management/diseas

e management

Alignment of Intermediate +

reablement + home-based care teams + Home-based care

teams

Disease management/self

care/wellness/independence

24/7ACCOUNTABILITY + CAPITATION-BASED

FUNDING

HEALTH + SOCIAL CO-COMMISSIONING

MCP + PACSNEW MODEL OF CARE

NEW INTEGRATED COMMUNITY-BED AND

HOME-BASED CARE MODEL

By 2016 – Community beds and home-based care?

• Joined up commissioning– Joint/Co-commissioning

• Providing joined up care – Provider Alliance Network

• Commissioning joined up care– Outcome-based population commissioning– New Contractual Model:

• Outcome-based contract • Payment-based alignment

ONE BED - Joined up commissioning

• ONE health and care BED – no distinction

• Co-commissioning/lead commissioner

• Better Care Fund vehicle

One service - providing joined up care – PAN

• PAN MODEL – merging and evolving• HYBRID – MCP and PACS• Primary Care led Organisation• Service Delivery

– Borough-based– Locality-based– Person/home-based

INCREMENTAL EXPANSION

Encompassing services

• General practice

• Community services

• Diagnostics

• IT alignment

Borough-Based Team

• Oversight/support

• Complex decision making

• Responsive care

• Care + support Planning/reablement

Patient, Family, carer

Case managementDisease managementSelf + wellness

Macro-integration (System)

Micro-integration (Clinical)

Meso-integration(Organisational)

Gateshead’s Integrated Community-bed and Home-based care Service

Provider Alliance NetworkN

ormative Integration

Borough-based provision

Core Health + Social care team across

Gateshead

MDTs + complex decision making

Governance /leadership

Establishing tools + care pathways +

monitoring outcomes

Locality-based provision

Locality team of Health + Social care

providers

GPs, social workers, nurses, therapist,

support workers, 3rd sector + voluntary

Ward rounds in community-beds + MDTs + supporting

discharge

Collaborative working within clusters across

practices and care home and neighbourhoods

Home-based/bed-based provision

Individuals providing care

within community-beds, people 's

homes and within the community

Prinicples of working• Assessment of care• Care planning (advanced

planning)• Coordinating care• Supporting clients and

carers/families• Advocacy work• Promoting

independence/wellness

2015/16 A primary care led organisation with

associated community and acute care alliances.

2016/17 A larger primary care led organisation

that sees wider alliances with community staff

across health and social care

2017/18 - established PAN will start to work

collaboratively with co-commissioners to

explore further alliances (e.g. private sector)

INCREMENTAL EXPANSION

One Outcome - Commissioning Joined up care

New Contractual Model• Type of Contract

– Alliance /Lead provider plus

• Outcome-based– High-value outcome measures (e.g. Quality)– Service integration measures (e.g. coordination and

continuity of care)

• Payment alignment– Outcomes + Integration– Client-needs = Unity of Currency (e.g. capitation)

– Pathways - Bundle payment + cycle of care  

Year 1- Health care alignment only

Year 2 - Health + public sector

alignment

Year 3- Health + public sector and

private sector alignment

INCREMENTAL EXPANSION

How will it work?

• Clinical /Management engagement

• Patient/public involvement

• Local ownership

• National Support

Aligning the system

5year plan vision

Health and Social care economy shifts:

• Move to value (from effectiveness, quality, safety)

• Move to culture (from structural redesign)

• Move to population planning (from individual)

• Move to collaborative system (from competitive provider landscape)

• Move to the ‘£’ – stewardship of system resource (from unaccountable ownership)

Next steps

• Central Team Visit – May 5/6th

• Finalising the 2 days – stakeholder day Wednesday 6th 9 – 12 noon

• Project plan:• Core Team• Commissioner and Provider – leads

» Payment + Funding» Contracting/outcomes» PAN » Commissioning

Any questions?