West Hampshire Clinical Commissioning Group

Transcription

1 West Hampshire Clinical Commissioning Group Quality serices, better health Kate Smith Senior Commissioning Manager Community Serices

2 What is the WHCCG? West Hampshire Clinical Commissioning Group (WHCCG) is led by local GPs and was set up in 2013 to plan and buy health care for our population of oer half a million people. Our area coers: 800 square miles of Hampshire, ranging from Whitchurch and Andoer in the north to Fordingbridge in the west and Lymington in the south. 53 GP practices Hospitals in Basingstoke and Winchester, Southampton, Salisbury and Lymington A range of community serices. Some specialist care, like cancer serices, are planned and purchased by our colleagues at NHS England.

3 Our ision, mission and alues Our ision: we will be consistently recognised for commissioning and enabling the deliery of high quality patient centred healthcare, which is innoatie, efficient, effectie and, where possible, preention based, contributing to the healthiest population in England Our mission: to improe the health of our population, by planning and funding high quality, safe and sustainable healthcare serices and working with a range of partners to ensure effectie and efficient deliery Our alues: in all our dealings we aim to be aspirational, innoatie, collaboratie, responsie and honest

4 Who are we? Fie local GPs hae been elected to sere on our Board alongside NHS managers, lay members and other specialist adisors. Our GP Board members are led by our chair, North Baddesley GP Dr Sarah Schofield supported by: Dr Nigel Sylester - Vice Clinical Chair Dr Tim Thurston Clinical Executie Director for Innoations and Research Goernance Dr Nick Arney Clinical Executie Director for Patient & Public Engagement Dr Simon Hunter - Clinical Executie Director for Clinical Goernance The West Hampshire CCG Board also has the following members : Heather Hauschild- Chief Officer Ruth Milton - Director of Public Health Mike Fulford - Chief Finance Officer Andrea O'Connell- Director of Quality and Safety Gill Duncan Director of Adult Serices, Hampshire County Council Ian Green Lay Adisor, Patient and Public Inolement Peter Bradshaw- Lay Adisor, Goernance Peter Lees - Secondary Care Adisor

5 Who are we? Board meetings are held in public eery other month and members of the public are welcome to attend. Contact for more information. The West Hampshire area is split into localities to make sure we keep a strong local focus on our planning. Each locality has a nominated lead GP to represent the area. Dr Rachel Barrass-Stones West New Forest Dr Karl Graham - Eastleigh Southern Parishes Dr Mike Jackson - Andoer Dr Andrew Isbister Winchester Dr Philipp Gregory Totton and Waterside Dr Dina Foy Eastleigh North and Test Valley South

6 West Hampshire Out of Hospital Strategy

7 Vision and Strategic Aim National Voices definition of integrated care as meaning person centred, coordinated care: I can plan my care with people who work together to understand me and my carer (s), allow me control, and bring together serices to achiee the outcomes important to me Strategic Aim Objecties Outcome People receie the right care in the right place and at the right time Maintain constant focus on long term quality of care and the achieement of outcomes for users Achiee long term quality outcomes Ensure fairness and equality in the broader context underpins eery decision we make Gie serice users and their families choice and control oer their own outcomes Promote greater care coordination Increase self sufficiency and independence, aoiding reliance on serices whereer possible and improing oerall experience Ensure our serices meet demand Work collaboratiely to delier integrated care serices that promote independence and recoery Protect the sustainability of serices to meet current and future demographic, financial and statutory requirements Ensure our system is financially sustainable

8 Out of Hospital Model Keeping Well: Early Interention and Effectie Care Co-ordination Care co-ordination is a holistic model, deliered by skilled health and social care practitioners in partnership with patients, carers and their GP Pro-actie risk profiling to identify high risk patients using predictie tools and the combined local intelligence of health and social care professionals Early diagnosis and interention Person Centred Care Planning with patients and carers as actie participants defining priorities, goals, programme implementation, coping strategies, contingency plans for crisis and outcome measures. The use of Personal Health Budgets and direct payments to enable patients greater choice, flexibility and control oer their own care and treatment Care planning to include self-care and supported self-management programmes to put the patient and their carers in control of their condition. This can include the use of assisted liing technology and irtual interention tools such as telehealthcare. Utilisation of community support and third sector serices, particularly where patients are isolated and hae no iable carer Care Co-ordination by named Case Manager; Telephone access to support as needed Proactie Interention Supporting Recoery If admission to an acute hospital is required, patients should only remain in hospital for the acute phase of their illness, with timely transfer or discharge. Patients should be supported to return home Strengthened Community Pull ; hospital in-reach supported by Daily Alert information Community beds (step-down) with early supported discharge either within or as close to a patients home as possible; ICTs able to direct use of community beds & out of hospital serices Care packages to be quickly reinstated, adapted to meet changing need or set up ia pooled budget Personal care and Welcome Home serices Admitting patients to hospital should be a last resort; with the majority of care proided in the community. Community serices need to be responsie to proactiely meet changing need Care naigation ia 111 or Care Coordinator; care in line with agreed plan Primary care urgent care centres Rapid access to consultant adice Rapid assessment clinics (including diagnostics); Integrated Rapid response & crisis interention serices ia SPA Access to community beds (step-up), home treatment and care support including night sitting. Rapid, flexible proision of care packages to meet need End of Life patients supported to die in place of choice Proactie management by SCAS enhanced paramedic role

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10 The Kings Fund Sam s Story

11 A Community Based Approach to Integrated Care Our approach: GP Practice Network 15 Integrated Care Teams (ICTs) coering 6 Localities Teams are co-located and work with a network of practices to foster meaningful partnerships Each Team coers a population of around 30,000 50,000 The core team consists of health and social care professionals including primary care, community nurses, therapists, social workers, and Older Persons Mental Health liaison workers. Each team has a named link Consultant Geriatrician The wider team consists of specialist serices Integrated Care Teams are rooted in communities they know and understand their community and actiely engage local oluntary organisations and support networks. ICTs proide a continuum of care based on indiidual need Integrated Care Team Specialist Serices Community Support Community based, primary care co-located model West Hampshire Localities Eastleigh & Test Valley Eastleigh Parkside Boyatt Wd St Andrews Pineiew Leighside Old Anchor Chandlers Ford Park & St Francis Fryern Brownhill Romsey Alma Rd Abbey Md Nightingale NorthBaddesley Eastleigh Eastleigh Southern Parishes Blackthorn Burseldon Hedge End West End St Lukes Winchester Winchester City Andoer Wincheste r Rural Winchester Winchester North Rural South Rural East Friarsgate Gratton B. Waltham St Pauls Stockbridge Twyford St Clements Whitchurch Wickham Stokewood Alresford Mansfield West Meon Andoer 1 Andoer 2 Shepherd s- CharltonSpring Hill Derrydown Andoer Adelaide St Mary s Totton/Waterside Totton & Lyndhurst Totton Testale Forest Gate Lyndhurst West New Forest Waterside Aon Valley Waterside Forestside Waterfront & Solent Fordingbridge Ringwood Cornerways Lymington Sway/Brock enhurst Twin-Oaks Chawton Wistaria & Milford New Milton Barton N.Milton Arnewood