ICCs Integrated Care Communities

Transcription

1 ICCs Integrated Care Communities Progress update to CCG Governing Body 3 rd October 2018 Tim Evans, Senior Responsible Officer ICCs Caroline Evans Management ICC lead 1

2 ICCs The ambition To improve outcomes for communities through closer working of primary care, social care, third sector organisations and community health services-providing better coordinated care Deliver more care in the community, nearer to home. To mobilise communities locally to become involved in health and care services and self - care approaches Phase 1-Reduce hospital admissions where possible and ensure people get home at the right time if they are admitted through proactive care planning. 2

3 ICC Development Headline Timeline ICC Coordination Hubs in place (IOC) Wave 1 Recruitment complete Rapid Response in place (IOC) Primary Care Investment additional staff in place (IOC) Integrated ASC Reablement & CPFT Rehabilitation via s75 agreement (IOC) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Admissions Avoided Reduced Bed Days ICC Performance Monitoring in place Hospital Based Discharge To Assess in place WCH (IOC) Frailty Coordination in place (IOC) Community Hospitals 43 WTE Transferred into ICCs V8.0 26/08/18

4 ICC Development ICC Hub IOC FOC Daily Huddle MDT Cockermouth and Maryport Carlisle Network Carlisle Healthcare Workington Copeland Brampton and Longtown Eden Solway and Keswick Professional of the day 4

5 Phase 1-the Elements ICC leadership trios, delivery groups and reference groups Coordination Hubs Rapid Response Daily huddles and weekly MDTs Acute based hub staff Supported discharge Home First in each A and E Frailty coordinators 5

6 Coordination Hubs One Tel number for coordinating care All 8 ICC Hubs are running 8am-6.30pm, Monday-Friday and working with CHOC out of hours 600 calls per week across all 8 ICCs (busiest are Copeland, Carlisle Network and Workington). All 8 Senior Hub Coordinators in post and 35 Hub Coordinators have been recruited. 1 Hub Coordinator has been appointed to be based in Cumberland Infirmary, Carlisle (CIC), and 1 for West Cumberland Hospital (WCH) 6

7 Rapid Response/Supported Discharge Teams in place in all 8 ICCs Professional of the day ongoing work to embed this new role MDT/Daily Huddles in place but at different levels of maturity Frailty coordinators commencing work in all ICCs 7

8 Home First Teams: Supporting patients to get home from hospital safely 7 days a week Extra 4 full time Therapists have been recruited to the Home First Team in WCH and will commence in October 2018 to extend this service. 4 Therapists already in place at CIC Work is ongoing with staff from community and acute on both sites to develop consistent approaches to service delivery, prioritisation and data collection. 8

9 Workforce & Recruitment Overall 90 new ICC posts have been filled either by new recruits or via the consultation process as the overnight beds closed at Alston, Wigton and Maryport. Staff Consultation process undertaken and completed with over 600 CPFT staff now all working across 7 days. Community Hospital staff in Wigton, Alston and Maryport have been offered other ward based and ICC community based posts through a consultation process. Section 75 agreement in development with CCC to formalise operational integration between NHS and Adult Social Care rehabilitation / reablement teams. New roles eg professional of the day, Home First 9

10 Community and hospital services - working together more closely One ICC Development Manager working in each acute hospital to improve interface with ICCs. Joint representation on a number of working groups including Flow Improvement Group, Acute Access Group and the ICC Integrated Management Group. Further work planned around admission avoidance pathways in respect of: Respiratory, CVD, falls and frailty. 10

11 Standardised reporting has been developed to support the work around stranded patients and to better understand the cohort. A baseline was taken 10/9/18. The current status is summarised below: Status 10/9/18 Baseline Updated 19/9/18 No. % Discharg Discharg ed ed Now DTOC Plan Not Medically Fit Unknown No. Still In Acute % Still in Acute DTOC % % Super-Stranded % % Stranded % % Totals % % It can be seen that of the original 163 Stranded and DTOC patients: 57.1% have been discharged This leaves 72 patients of which: o 22 (30.6%) are currently not medically fit for discharge o 27 (37.5%) are DTOCs and are therefore being actively managed by the IDT o 15 (20.8%) are medically fit and have a plan against them o 8 (11.1%) there is no clear plan and this will be followed up. 11

12 ICCs-the challenges Engaging communities Engaging the whole workforce-all sectors Pace-working across the system-each organisation needs to sign up to pathways etc Engaging the public and investing time Leadership capacity to deliver the changes-work ongoing to move capacity to ICCs in the near future Measuring impact-quality and performance 12

13 ICCs-one of our successes Hub contacted by Palliative Care Social worker regarding someone on a hospital ward at the end of their life. Patient was deteriorating fast and palliative care social worker asking hub what could be put in place to facilitate discharge Hub liaised with OT and unscheduled nurse for rapid response, who arranged to meet family at home and put repose mattress and glide sheet in situ, and check that sufficient support was in place for the family. Patient was discharged from hospital that afternoon with support. Patient passed away at home (preferred place) with family around them next day Previously the social worker would need to find different numbers, call different teams and try to coordinate the response for the patient-the hub now coordinates the care and the response is rapid 13

14 Continued successes A patient who needed intravenous drugs for 40 days and would have stayed in hospital-was able to go home and be treated at the new Maryport Day unit A patient on the Eden Unit waiting for 4 calls a daythe team worked with the medical team and found a new solution for medication-went home with 2 calls a day from the rapid team People who are delayed in hospital-lowest figures in Community Hospitals-previously 33 per day, now 10 per day with shorter waits. 14