NHS Support for Social Care PROGRAMME PLAN 2013/14

NHS Support for Social Care PROGRAMME PLAN 2013/14

Version: FINAL 7.0 Author(s): Jackie Raven Date Published: June 2013 Page 2

CONTENTS PAGE 1.0 INTRODUCTION 4 1.1 Purpose of Document... 4 1.2 Vision... 4 1.3 Aims... 4 1.4 Objectives... 5 1.5 Benefits... 5 1.6 Risks... 5 1.7 Governance... 6 1.8 Overall Performance Indicators... 6 2.0 PROJECT PORTFOLIO 7 2.1 Project 1: Enhanced Hospital Discharge... 8 2.2 Project 2: Crisis Response Service... 9 2.3 Project 3: Mental Health Support... 10 2.4 Project 4: Falls Prevention Service... 11 2.5 Project 5: Combined Rapid Response and Reablement Service... 12 2.6 Project 6: Carer Support... 13 2.7 Project 7: Stroke... 14 2.8 Project 8: ICES... 14 3.0 PROGRAMME SCHEDULE 15 3.1 Milestones and Deadlines... 15 3.2 Total Costs... 16 4.0 MONITORING 17 4.1 Performance Monitoring... 17 4.2 Responsibility for Reporting... 17 Page 3

INTRODUCTION The 2011/12 NHS Operating Framework set out details of non-recurrent allocations for social care for 2011/12 fiscal year, 2012/13 fiscal year; From 2013/14 the NHS England will carry out this function and transfer. The Isle of Wight Clinical Commissioning Group (CCG) was allocated 2.13m for 2011/12 fiscal year for this purpose, 2.05m for 2012/13 fiscal year and 2.7m for the 2013/ 14 fiscal year. The funding must be used to support adult social care services in each local authority, which also has a health benefit. However, beyond this broad condition, the Department of Health has made it clear that funding is to provide flexibility for local areas to determine how this investment in social care services is best used. Regard must be given to the Joint Strategic Needs Assessment and existing commissioning plans for both health and social care, in how the funding is used. The funding must also make a positive difference to social care services, and outcomes for service users. The funding may, also be used to support existing services or transformation programmes, where such services or programmes are of benefit to the wider health and social care system, provide good outcomes for service users, and which would be reduced because of budget pressures in local authorities without this investment. 1.1 Purpose of Document The purpose of this document is to outline the projects that will be funded using the nonrecurrent allocations for social care, for 2013/14 fiscal year. 1.2 Vision The vision for the investment into social care services will be to benefit provide flexibility in the investment into Social Care, has an overall health gain and that makes a positive difference to the health and well-being of the local community. 1.3 Aims The programme aims are to: Improve social care and health outcomes. Promote recovery from illness, minimise dependence and reduce reliance on long term care and support by maintaining people in their own homes and communities for as long as possible. Prevent unnecessary admissions to long term residential homes and secondary care services. Ensure safe, timely discharge from care homes with nursing, residential homes and from secondary care services when a person is medically fit; Promote greater integration and joint working between health and social care; and Enable progress with implementation of joint priorities identified in the Joint Strategic Needs Assessment. Page 4

1.3 Objectives The programme objectives are to: To commission directly, or via a personal budget, local services to provide equitable access to support, in the service users and family s place of choice when reasonably practicable and as required, in line with service user needs; To effectively support service users to become independent, reducing reliance on long term care; To commission directly, or via a personal budget, local services in the right setting to ensure inappropriate residential, care home with nursing and hospital admissions are avoided and that service users are discharged from secondary care without delays into the right setting; To encourage partnerships across organisations to ensure seamless transition of care; and To effectively and regularly collect relevant data for performance monitoring purposes, for effective commissioning of services and for future decision making. 1.4 Benefits 1.5 Risks The expected programme benefits are: Service user health and social care outcomes will be improved; Service users will be supported to become independent and less reliant on long term care; Service users will not be admitted into long term residential care or secondary care unless required; When an admission to residential or secondary care is required, safe, timely discharge from those services when the person is able to manage in an alternative setting ; There will be greater integration and joint working between health and social care; and Progress will be made with the implementation of joint priorities identified in the Joint Strategic Needs Assessment. The expected programme risks, preventing the implementation of the project areas, are: Stakeholders goals may conflict; Communication issues may arise; A lack of engagement may be seen from the public and professionals; The lack of recurrent investment may deter professionals, which could hinder the recruitment phases and cooperation with different organisations; and Due to restructuring within organisations, key stakeholders may change reducing continuity of delivery. Whilst this document sets out both organisations current expectations with regard to the NHS Support for Social Care. It is possible that, over time, the strategic objectives of either body could change. For instance, change could be driven by changes to national funding streams or as an outcome of the results of the local elections. Changes of this nature may warrant the need to develop a different planned programme of delivery. Page 5

1.6 Governance The proposals are to be agreed by the Local Authority and the Isle of Wight CCG and signed off by NHS England. It is envisaged that governance will be directly provided by the Isle of Wight Health and Wellbeing Board to ensure delivery. The board will be supported by the NHS Support for Social care steering group who will direct progress. It is intended that the Steering Group will normally meet every 3 months and will provide advice and input into the delivery of the above objectives. Update and solution finding as required will take place during the Head of Commissioning ASC and Deputy Chief Officer CCG will take place on a monthly basis. This group will, in turn, report to the Isle of Wight Health and Well being board on a quarterly basis. The Deputy Chief Officer will present report and outcome of Health and Well-being Board discussions to the CCG Board on a quarterly basis. The steering group is responsible for: Achieving the deliverables set out in Programme Plan; Overseeing progress against agreed delivery targets; Managing risks and issues and escalating to the Isle of Wight health and Well-being Board; Managing the critical dependences of the project as a whole and prioritise developments in order to match available change management capacity and resources; Approving joint Local Authority and CCG key documentation; Disseminating information about the project to the appropriate stakeholders; and Ensuring that the project remains on course to deliver its final outcome. The steering group has authority to: Own and advise on steering group / sub-group level risks and issues; and Recommend change requests to the Isle of Wight Health and Well-being board. 1.7 Overall Performance Indicators Reduction in admissions to long term care; Increase in weekend completion of social care assessment in St Marys Increase in Social care supported discharged from St Marys Increase in carers assessments Reduction in non-elective admissions; The number of situation reports reportable delayed transfers of care (DToC) actual number as currently measured; Reduction in the number of DToC as a % of available beds; Reduction in readmissions within 30 days of discharge; Reduction in average emergency length of stay excluding 0 1 days; Reduction of acute Mental Health admissions, on 2011/12 baseline; Reduction of acute Mental Health readmissions within 28 days, on 2011/12 baseline; and Reduction of Length of Stay (LOS) in Mental Health rehabilitation beds, on 2011/12 baseline. Page 6

PROJECT PORTFOLIO The project portfolio includes seven overarching strategic projects streams: Project 1: Enhanced Hospital Discharge Project 2: Crisis Response Service Project 3: Mental Health Support Project 4: Falls prevention Service Project 5:Combined Rapid Response and Reablement Project 6: Carer Support Project 7: Stroke Project 8: ICES These overarching strategic projects streams are outlined in further detail throughout this section. Page 7

1.8 Project 1: Enhanced Hospital Discharge Project Title Project Lead Project Outline N.B: This project is separated into three project areas Enhanced Hospital Discharge Debbie Morris To further enhance timely discharge from St Marys Hospital by increasing current Social Care staff establishment which will:- Seek to provide weekend cover and the opportunity to complete social care assessments 7 days a week; to trial social care staff being based on the wards To support the discontinuation of use of Social Care notification Forms A+B thus reducing administrative time for both nurses and social care staff. Part of the allocation requested will be required to support Community Care budget as it is anticipated that service users will be receiving social care at earlier stage. This to include wider support for those with Mental Health issues and dementia. Key Stakeholders Jackie Raven, Rachael Weeks Costings Total available: 1,038,338 This is broken down by: Care package cost to facilitate hospital discharge 846,338 Hospital Care Management (4 posts inc overheads) 192,000 Deliverables Improved outcomes for the individual Earlier supported discharge Improved communication between health and Social care staff Reduction of administrative time to both health and social care by the removal of the Discharge notification forms. Performance Indicators Q1 Q2 Q3 Q4 1a 5% social care assessments completed at the weekend ; 1b 1c 5 % reduction on length of stay. 2% discharge supported by social care completed at the weekend Outcome Risks and Constraints DSO10 Adults maintain their independence and are actively involved within their communities Changes in the organisational structures and any future change in strategic direction which may affect performance or prevent the deliverables being achieved. Alternative care settings in the community may not be able to accommodate any increase in demand, which may reduce timeliness of transfer from secondary to primary support. Community services may not be able to support weekend discharges Page 8

1.9 Project 2: Crisis Response Service Project Title Project Lead Crisis Response Service Yasmin Wills Project Outline Direct access to IW funded beds at Adelaide & Gouldings = 15 beds in total, these include previously GP and ILRC dedicated bends. Respite Service - Ryde House (1 Bed) Urgent GP Nursing Beds (2 Beds) Assistive Technology - Equipment Key Stakeholders Debbie Morris / Gillian Baker / Gill Kennett Costings Total available: 805,284 This is broken down by: Direct access to IWC funded beds at Adelaide and Gouldings: 522,600 Respite Service - Ryde House (1 Bed @ 667 p/w): 34,684 Urgent GP Nursing Beds 140,000 Assistive Technology - Equipment: 108,000 Deliverables Improved outcomes for the individual Reduction in admission to hospital; Reduction of crisis residential placements; Enhanced reablement to support project with access to Physiotherapy Performance Indicators 2a Q1 Q2 Q3 Q4 At least 70% occupancy of each IWC funded bed, on 2012/13 baseline 2b At least 75% occupancy of each Respite funded bed, on 2012/13 baseline 2c At least 75% occupancy of each Urgent GP Nursing bed, on 2012/13 baseline 2d NI125 Achieving independence for older people through rehabilitation/intermediate care Outcomes Risks and Constraints DSO12 People are supported at times of crises to maximise their health, wellbeing and independence. Implementation of this service area may not be achieved if there is a lack of: Cooperation with a range of organisations; Page 9

1.10 Project 3: Mental Health Support Project Title Project Lead Project Outline Key Stakeholders Mental Health Support Sue Lightfoot Support to Mental Health reablement service through enhanced reablement capacity; Support for individuals with complex care needs; and Ensuring individuals with complex Mental Health needs are supported to live independently. Kim Ball and Mark Howell Costings Total available: 147,000 This is broken down by: Support care Officers at Woodlands (4 posts) - 108,000 Social Work Support at Woodlands (1 post) - 39,000 Additional funding will be made available from IWC Housing Related Support to assist with rents. Deliverables Person centred outcomes achieved Stable housing Support to access training / works Reduction in MH admission and readmissions Reduction in length of stay Performance Indicators 3a 3b 3c Q1 Q2 Q3 Q4 30% reduction of acute Mental Health admissions, on 2012/13 baseline 10% reduction of acute Mental health readmissions within 28 days, on 2012/13 baseline 10% reduction of Length of Stay (LOS) in Mental Health rehabilitation beds, on 2011/12 baseline 3d 3e Baseline percentage of patients in rehabilitation beds during 2012/13 Baseline the number of patients supported to live independently during 2012/13 Set a percentage target in-year Set a percentage target in-year 3f NI125 Achieving independence for older people through rehabilitation/intermediate care Outcomes Risks and Constraints DSO12 People are supported at times of crises to maximise their health, wellbeing and independence. Implementation of this service area may not be achieved if there is a lack of: Cooperation with a range of organisations. Page 10

Project 4: Falls Prevention Service Project Title Project Lead Project Outline Key Stakeholders Comprehensive Falls Service Gill Kennett / Pieter Joubert The Falls Prevention Coordinator will be responsible (among other responsibilities) for training the carer workforce, both in residential and homecare settings. This will link with the common risk assessment process. Lorraine Bower, Lyn Turner: Safeguarding ; Debbie Morris and Yasmin Wills. Costings Total available: 61,000 This is broken down by: Falls Co-Ordinator Post (NHS Band 7) 51,000 Falls Training: 10,000 Deliverables Reduction in falls leading to reduction in ambulance responses, A&E attendance and admission to hospital for fractures in the older population. Increased percentage of fragility fracture patients managed in accordance with national guidelines Performance Indicators 4a 4b Q1 Q2 Q3 Q4 Baseline of the total carers in post in Residential/ Homecare setting 5% of the total identified carers trained in helping service users prevent a fall in a Residential/ Homecare setting. Baseline total number of hospital admissions for patients with a fracture resulted from a fall 2012/13 by the 30th April 2013. Set percentage reduction in the number of admissions for patients with a fracture resulted from a fall, on 2012/13 baseline by the 18th May 2013. Outcomes Risks and Constraints DSO16 - As the result of improved joint working with NHS, fewer frail people are admitted as emergencies to hospital; those that are stay for shorter periods of time and stand an improved chance of returning to their own homes Placing the service in the hands of one person will produce a risk if they re absent. The demand will exceed capacity through an influx of community enquiries. If this occurs, management through the Urgent Care Hub should be pursued. The increased flow of appropriately screened patients will outstrip current resources, with the highest risk being an increase in referrals for stability exercises and the falls clinic. If this occurs, the appropriate use of the Map of Medicine pathway for falls will maximise efficiency. The increased identification of patients with osteoporosis will lead to increased prescription costs. If this occurs, the increased costs should be balanced by savings after 12 months of treatment and will increase with the passage of the next 3 years to a plateau. Page 11

Project 5: COMBINED RAPID RESPONSE & REABLEMENT Project Title Project Lead Project Outline Key Stakeholders COMBINED RAPID RESPONSE & REABLEMENT Debbie Morris / Kim Ball The Local Authority will seek to develop a combined Rapid Response and reablement service which supports the person from the time of requiring urgent social care interventions, through reablement whilst actively seeking out opportunities to enhance the person s well-being and independence, this service will also enhance current take up of Telecare. This funding will also assists in supporting the Community Care budget in relation to increased activity. The main focus will be to improve the initial assessment, linking this with the CAF and trusted assessors agenda s; and to ensure that all service users receive a weekly review during the reablement phase of support. Mark Howell, Jackie Raven and Gill Kennett Costings Total available: 392,000 Support Workers to develop service 250,000 Development of night workers and sickness response 142,000 Deliverables First Response and Reablement being combined to support non statutory initial assessment Delivery of Reablement which links with Healthcare Rehab services Timely and appropriate discharge once the person reaches the potential Supported transfer to long term servces Increased uptake of telecare Performance Indicators 5a Q1 Q2 Q3 Q4 Adults are successfully discharged from hospital and readmission levels decrease by 2% 5b Number of same day assessments completed baseline 2013 / 2013 Outcomes Risks and Constraints DSO12 People are supported at times of crises to maximise their health, wellbeing and independence. Implementation of this service area may not be achieved if there is a lack of: Cooperation between IWC services; Failure to engage staff Inability to re-build core business and social care practitioner practice Any future transfer to health rushed through without these proposals being allowed to be embedded in practice therefore returning IWC to increased risk of financial overspend. Possible future adjustments to the strategic direction of the local authority Page 12

Project 6: Carer Support Project Title Project Lead Project Outline Key Stakeholders Carer Support Yvonne Millmore The Commissioning Officer (Carers) who will be responsible for reviewing, refreshing and delivering the joint Health and Social Care Isle of Wight Carer s Strategy. Gillian Baker and Jackie Raven Costings Total available: 95,000 This is broken down by: Carer s Commissioning Officer post: 45,000 Training and development: 10,000 Service developments : 40,000 Deliverables The joint Health and Social Care Isle of Wight Carer s Strategy will be refreshed, ensuring that carers have the opportunity to have a break and that comprehensive information, advice and training is available to them; To develop a carers SSAQ and RAS; Develop annual health checks; Improved outcomes for carers; Increasing access to respite care; and Support Young carers. Performance Indicators 6a Q1 Q2 Q3 Q4 Baseline the number of carers identified as requiring needs assessments Increase in the percentage of carers receiving needs assessment to be established in-year, on 2012/13 baseline 6b Baseline the numbers in receipt of respite care Increase in the percentage of people receiving respite care, to be established in-year, on 2012/13 baseline 6c Baseline carer satisfaction levels for 2012/13, focusing on carers feel supported to undertake caring role Set a target for the percentage increase in carer satisfaction levels in-year, in line with the ASCOF (Adult Social Care Outcomes Framework). 6d NI 135 33% of carers have had an assessment or review and have received a specific carer s service, advice or information (Measured as a percentage of all clients receiving a service). Outcome Risks and Constraints DSO9 - People organise their own care and support through the use of Personal Budgets wherever possible, giving individuals and their carers the ability to direct their own lives. Carers do no utilise this support, as they are not motivated to do so, or they do not know how to access the service. Page 13

Project 7: Stroke Project Title Project Lead Project Outline Key Stakeholders Stroke Yvonne Millmore Support to Stroke Association for family Gillian Baker and Jackie Raven Costings Total available: 89,506 This is broken down by: Communications Support: 31,402 Family and Carers Support: 58,104 Deliverables Stroke victims and families supported to live independently Performance Indicators 7a Q1 Q2 Q3 Q4 Baseline of the number of stroke victims and their families supported to live independently Increase on the number of stroke victims and their families supported to live independently, target to be developed in-year Outcomes Risks and Constraints DSO15 There is access to advice, information and guidance so that people have improved options on managing their lives The Stroke Facility Coordinator is not in post due to inability to recruit. Service Users are unable to access the service, due to lack of communication of the service availability. Stroke victims are not independent follow use of service, due to issues with the service provision or ongoing support. Project 8: ICES Project Title Project Lead Project Outline Key Stakeholders ICES Daron Perkins To provide additional equipment for the Integrated Community Equipment Store Jackie Raven; Rachael Hayes Costings Total available: 115,000 Deliverables Additional equipment one off payment Page 14

2.1 Milestones and Deadlines QUARTER 1 (April 2012 July 2012) 1. 2. 2.0 PROGRAMME SCHEDULE Milestone Deadline Who 1 st Quarterly Review Meeting: Performance Progress Monitoring Projects 1 8: Report on Quarter 1 performance/baselines/ Progress 30 th July 2013 CCG/IOW Council 30 th July 2013 IOW Council QUARTER 2 (July 2012 - October 2012) 3. 4. 2 nd Quarterly Review Meeting: Performance Progress Monitoring Reports from the Isle of Wight Council Projects 1 8: Report on Quarter 2 performance/baselines QUARTER 3 (October 2012 - January 2013) 5. 6. 3 rd Quarterly Review Meeting: Performance Progress Monitoring Reports from the Isle of Wight Council Projects 1 8: Report on Quarter 3 achievement of performance indicators QUARTER 4 (January 2013 - March 2013) 7. 8. 4 th Quarterly Review Meeting: Performance Progress Monitoring Reports from the Isle of Wight Council Projects 1 8: Report on Quarter 4 achievement of performance indicators 28 th Oct 2012 CCG/IOW Council 28 th Oct 2012 IOW Council 31 st Jan 2014 CCG/IOW Council 31 st Jan 2014 IOW Council 29 th March 2014 29 th March 2014 CCG/IOW Council IOW Council Page 15

IWC FINANCE REPORT FOR: NHS SUPPORT FOR SOCIAL CARE NHS SUPPORT FOR SOCIAL CARE PERIOD: APRIL 2013 - MARCH 2014 Description of spend 1) ENHANCED HOSPITAL DISCHARGE Notes YEAR 3 2013/14 Allocated Funding ( 2.7m) Care package cost to facilitate hospital discharge 846,338 Hospital Care Management (4 posts inc overheads) Will require 3 yr funding 192,000 sub total 1,038,338 2) CRISIS RESPONSE SERVICE Direct access to IW funded beds at Adelaide & Gouldings 6 GP Beds & 9 ILRC beds = 15 beds in total 522,600 Respite Service - Ryde House (1 Bed @ 667 p/w) 34,684 Urgent GP Nursing Beds (6 Beds) 140,000 Assistive Technology - Equipment Includes slippage from combined rapid response 108,000 sub total 805,284 3) MENTAL HEALTH SUPPORT Social Care Officer at Woodlands Centre (4 posts) Possible funding from Housing Related Support 108,000 Social Worker at Woodlands (1 post) 39,000 sub total 147,000 4) FALLS PROVENSION SERVICE Falls Co-Ordinator Post (NHS Band 7) inc travel 51,000 Falls training 10,000 sub total 61,000 5) COMBINED RAPID RESPONSE & REABLEMENT Support Workers to develop service 10 months of funding as at 31/05/13 250,000 Development of night workers and sickness response 10 months of funding as at 31/05/13 142,000 sub total 392,000 6) CARERS SUPPORT Carers Commissioning Officer post On-going base budget required 45,000 Training and development 10,000 Service developments 40,000 sub total 95,000 7) STROKE Communication Support grant to Stroke Association 2014/15 funding via Health 31,402 Family & Carers Support grant to Stroke Association On-going base budget required 58,104 sub total 89,506 8) ICES Additional equipment Isle of Wight allocation: 2,743,128 On-going base budget required for future year 115,000 investment sub total 115,000 TOTAL FUNDING 2,743,128 Page 16

3.1 Performance Monitoring 3.0 MONITORING The schemes and outcomes will be monitored quarterly at the Isle of Wight Health and Well being Board. Via Isle of Wight Council, the social care and health project leads are expected to formally report on the achievements, including achievements on the performance indicators, given in Section 2 of this document. Any issues affecting the delivery of the projects within the portfolio, and the deliverables and performance indicators, should be properly raised upon event at the steering group. Contingency plans should be developed by the Isle of Wight Council and / or the CCG depending on the project lead. 3.2 Responsibility for Reporting The Isle of Wight Council will be responsible for reporting to the Isle of Wight Health and Well-being Board. NHS England will be monitoring the spending made by the Isle of Wight Council. The methodology for this is still to be determined. Page 17