Imagine Inspire Innovate...and Integrate

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1 Imagine Inspire Innovate...and Integrate Dr Anne Hendry National Clinical Lead for Integrated Care JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing

4 Health Inequalities

6 Population billion budget 14 Health Boards 32 Local Government Authorities Integrated healthcare delivery system Universal coverage Free personal care for 65+ New legislation to integrate health and social care

7 JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 7

8 JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 8

9 15 th International Conference on Integrated Care Edinburgh March 2015 Innovations in Integrated Care in Europe and Around the World

10 Seven Key Lessons (Goodwin, 2015) Theme 1 Population-health management 2 Primary and secondary prevention 3 Personalised care co-ordination Characteristics The ability to have an in-depth understanding of the health needs of communities supported through data that can provide intelligence on the priorities that should be addressed The ability to support people to live better with their conditions, for example through educational programmes or self-care support The ability to plan and co-ordinate services effectively around people s needs helps to overcome fragmentations and improve care experiences ad outcomes 4 Effective ICT systems Care professionals must be able to communicate well with each other and people must be able to interact effectively with care providers in a way that supports shared decision-making. 5 Integrated delivery system 6 Building social capital and collaborative capacity 7 Research and evaluation Care systems need to be responsive to people s needs, especially during times of crisis. The inability of provider networks to respond in real-time means that care co-ordination efforts are undermined. Promoting shared values and understanding can help provide the necessary commitment to take integrated care forward. Measuring, monitoring and responding to evidence to judge or benchmark care quality and outcomes is essential to improving quality of care through integration

Integrated Care in UK Structural solutions and payment reforms are insufficient Need policies and governance arrangements that enable health and social care to work together Organisational stability,

11 Integrated Care in UK Structural solutions and payment reforms are insufficient Need policies and governance arrangements that enable health and social care to work together Organisational stability, leadership continuity and time to nurture new models of care Address professional, cultural and behavioural issues JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 11

12 Current paradigm System geared towards acute / single condition Hospital centred Doctor dependent Episodic care Disjointed care Reactive care Patient as passive recipient Self-care infrequent Carers undervalued Low-tech Future paradigm System designed around people with multiple conditions Embedded in communities and their assets Multi-professional and team based care Continual care and support when needed Well coordinated integrated health and social care Preventive and anticipatory care Informed empowered patients and clients Self management / self directed support enabled Carers supported as equal partners Technology enables greater choice and control

13 Route Map to Future State Imagine a shared future - co-create a coherent vision, meaning and purpose through dialogue with patients and carers, the public, health and care professionals, policy makers and politicians Inspire people to be the change - build commitment, energy, leadership and improvement capacity and capability at all levels Innovate for equity and value adopt technology and new models of care that build on the assets and resilience of local people and deliver the right outcomes for local communities Integrate care value the contribution of all partners, build trusting relationships between different professionals and care teams, and coordinate care and support across care settings and agencies JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 13

14 Public Service Reform in Scotland

15 What Matters to Me Coordination and continuity of care Trusted relationships Accessible information and advice Good communication with, and between, staff

16 2020 Vision for Quality Everyone is able to live longer healthier lives at home or in a homely setting. Integrated health and social care, with a focus on prevention, anticipatory care and supported self management. Care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. There will be a focus on ensuring that people get back to their home or community as soon as appropriate, with minimal risk of readmission. JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 16

17 Policy Alignment JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

18 Delivery Focus ROUTE MAP TO THE 2020 HEALTH AND SOCIAL CARE VISION FOR SCOTLAND Triple Aim Quality Ambitions 12 Priority Areas for Improvement Person Centered Person Centered Care Safe Safe Care Primary Care Quality of Care Unscheduled and Emergency Care Integrated Care Care for Multiple and Chronic Illnesses Early Years Effective Health of the Population Health Inequalities Prevention Workforce Value and Sustainability Innovation Efficiency and Productivity

19 Getting to the Third Curve Performance Improvement Co-production, and personal Outcomes Performance Time

20 31-Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug-05 Individual Value Improvement Length of Stay LMH Average of 80% patients 30 Special Cause Flag Month/Year

21 Improvement Network A cross sector collaborative to support innovation and test and spread actions which collectively improve outcomes through: WebEx virtual meetings and e-bulletins Web portal to share good practice, evidence and resources Digital stories and learning from the experience of people Training in use of improvement methodologies Synergy with Communities of Practice and networks Use of measurement for improvement and benchmarking Planning for sustainability Support for coproduction and outcomes-based approaches JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 21

22 Leadership JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 22

23 Courageous Leadership It requires vision, initiative, patience, respect, persistence, courage, and faith to be a transforming leader. S Covey

24 Public Finances Fall in Government Expenditure

25 Projected % change in Scotland s population by age group,

27 Non anonymised data

28 Beds Demographic change for population aged 65+ Scotland Potential impact on emergency bed numbers % 24% 41% 61% 84% Y/E Mar 2007 Projected 2011 Projected 2016 Projected 2021 Projected 2026 Projected 2031 Year Calendar year 07 estimate JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors P Knight Scottish Government

Reshaping Care for Older People 10 Year Programme to 2021 300 million Change Fund 2011-15 32 Partnerships between NHS: primary, acute, mental health LA: social care & housing Third and Independent

29 Reshaping Care for Older People 10 Year Programme to million Change Fund Partnerships between NHS: primary, acute, mental health LA: social care & housing Third and Independent sectors Older people and carers Change Plans signed off by all partners 20% of funding to be invested in direct or indirect support for carers JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 29

30 Reshaping Care Pathway

YEARS 1300 PER DAY FEWER PEOPLE AGED 65+ IN HOSPITAL BEDS THAN EXPECTED IN RECEIPT OF FORMAL CARE AT HOME HAVE

32 39% CHANGE FUND SPEND 2014/15 SUPPORTED CARERS 2 Million MORE DAYS IN OWN HOME THAN EXPECTED 17% FEWER OLDER PEOPLE CONVEYED to HOSPITAL after a fall (non-injured) 10% REDUCTION IN RATE OF 75+ EMERGENCY BEDDAYS OVER 4 YEARS 1300 PER DAY FEWER PEOPLE AGED 65+ IN HOSPITAL BEDS THAN EXPECTED IN RECEIPT OF FORMAL CARE AT HOME HAVE TELECARE 4000 PER DAY FEWER PEOPLE IN CARE HOMES THAN EXPECTED 19% FEWER PEOPLE DELAYED IN HOSPITAL OVER 2 WEEKS

33 People living in more deprived areas in Scotland develop multiple conditions around 10 years before those living in the most affluent areas

34 Mental health problems are strongly associated with the number of physical conditions, particularly in deprived areas in Scotland

35 Public Bodies (Joint Working) (Scotland) Act People are supported to live well at home or in the community for as much time as they can and have a positive experience of health and social care when they need it All adult care groups +/- children s services & criminal justice Principles for integrated health and social care Strategic and locality planning based on population needs Integrated governance : body corporate or lead agency Chief accountable officer has integrated oversight of delivery Integrated budgets for health and social care Nine national outcomes for health and wellbeing JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 35

36 Expendiure ( m) Integrated Resources - Minimum to be delegated 14,000 Scotland total = 12.3bn 12,000 10,000 8,000 Minimum to be delegated to Integration Authorities = 7bn 6,000 4,000 2,000 0 Hospital Community Health Family Health Services & Prescribing Social work

37 Health and Wellbeing Outcomes JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 37

40 South Ayrshire Health & Social Care Partnership

41 Building effective relationships and creating local integrated networks of care and support

42 Stuart Cumming Forth Valley System Diagnostic Services Integrate d Care Pathway Specialist Learning Disability Service Management Plans, LOS, Ward Reconfiguration General Practice and Nursing Teams Community Pharmacy Mental Health & Learning Disability Support Complex Care Services Secondary Care Anticipatory Care Planning Whole Person Specialist Nursing Workforce Community Hospital & Intermediate Beds Model Rehabilitation / Early Intervention REACH Daycare Redesign Specialist Mental Health Services Telecare Responsive Social Care Services Supported Self Mix Individual Carer Support Employability & Training Enhanced Self Directed Support Carer Support e.g. Acute, Hospital Liaison Ambulatory Care including: AAU, CAU, ED Review OOH (24/7Health & Social Care) Family & Community SAS See & Treat CORE LOCALITY NETWORK Enabling Integrated Team Development Older Peoples Services & Children's Services EXTENDED LOCALITY NETWORK ACUTE SERVICES NETWORK Third Sector Other Community Services: Police, Education / Care Homes Tertiary Care Reshaping Care for Older People REACH & Specialist Rehab Hospital & Home including: AHP weekend support, Overnight Care, Rehab at Home Enhanced Discharge & Discharge Planning Whole Team

Whole System Diagnostic Services Integrate d Care Pathway

LOS, Ward Reconfiguration General Practice and Nursing Teams

Support Complex Care Services Secondary Care Anticipatory

Community Hospital & Intermediate Beds Model Rehabilitation

Mental Health Services Telecare Responsive Social Care

Employability & Training Enhanced Self Directed Support

Acute, Hospital Liaison Ambulatory Care including: AAU, CAU,

SAS See & Treat CORE LOCALITY NETWORK Enabling Integrated

Services EXTENDED LOCALITY NETWORK ACUTE SERVICES NETWORK

Care Homes Tertiary Care Reshaping Care for Older People

43 Whole System Diagnostic Services Integrate d Care Pathway Specialist Learning Disability Service Management Plans, LOS, Ward Reconfiguration General Practice and Nursing Teams Community Pharmacy Mental Health & Learning Disability Support Complex Care Services Secondary Care Anticipatory Care Planning Whole Person Specialist Nursing Workforce Community Hospital & Intermediate Beds Model Rehabilitation / Early Intervention REACH Daycare Redesign Specialist Mental Health Services Telecare Responsive Social Care Services Supported Self Mix Individual Carer Support Employability & Training Enhanced Self Directed Support Carer Support e.g. Acute, Hospital Liaison Ambulatory Care including: AAU, CAU, ED Review OOH (24/7Health & Social Care) Family & Community SAS See & Treat CORE LOCALITY NETWORK Enabling Integrated Team Development Older Peoples Services & Children's Services EXTENDED LOCALITY NETWORK ACUTE SERVICES NETWORK Third Sector Other Community Services: Police, Education / Care Homes Tertiary Care Reshaping Care for Older People REACH & Specialist Rehab Hospital & Home including: AHP weekend support, Overnight Care, Rehab at Home Enhanced Discharge & Discharge Planning Whole Team

Integrated Interdisciplinary Care and Support working seamlessly with colleagues in NHSScotland and partners who provide care making more and better use of technology and facilities to

44 Integrated Interdisciplinary Care and Support working seamlessly with colleagues in NHSScotland and partners who provide care making more and better use of technology and facilities to increase access to services strengthening workforce planning to ensure the right people, in the right numbers, are in the right place, at the right time putting new and extended roles into practice

45 Peer support and web based information and advice to help people manage their conditions

46 Community Connectors

47 Local Partnerships with Third Sector

48 Social Movement

49 Innovation in General Practice: House of Care

50 Technology Enabled Primary Care - Right First Time, All the Time

52 Intermediate Care Rapid Response / Early Supported Discharge Reablement Homecare Step Up / Step Down community beds Hospital at Home JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors

53 North Lanarkshire Patients accepted by ASSET in 29 Months 2,864 76% Supported at Home 76% are managed in their own home instead of Hospital by the ASSET team 5.7 days Length of Stay 5.6 / Day Beds Closed 50 Value 2Million+

Critical success factors Purpose and Leadership Share a common vision and purpose, understood and accepted as important by each partner Outcomes and Customer Focus Always focus on

partnership and within partner organisations Learning and Innovation Continuously seek improvements in activities and ways of working, learning from each other and from elsewhere

54 Critical success factors Purpose and Leadership Share a common vision and purpose, understood and accepted as important by each partner Outcomes and Customer Focus Always focus on outcomes and work together to satisfy the needs and expectations of customers Culture and Communications Promote can do values and effective communications at all levels within the partnership and within partner organisations Learning and Innovation Continuously seek improvements in activities and ways of working, learning from each other and from elsewhere Management for Partnership Performance Put in place necessary management practices, using information, data and resources effectively, and manage changes needed to achieve partnership goals

56 Integration JIT is a strategic improvement partnership between the Scottish Government, NHS Scotland, CoSLA, the Third Sector, the Independent Sector and the Housing Sector 56

Appendix 1: South Lanarkshire H&SCP Improvement Plan 2017/18.

Appendix 1: South Lanarkshire H&SCP Improvement Plan 2017/18. South Lanarkshire - Whole System Pathway Indicators identified capture key data across the whole H&SC system, primarily based around supporting