Integrated Care and Support Collaborative: Pioneer Scheme 2013 13 th December 2013 Greenwich Co-ordinated Care
Our Vision and Main Aims The Greenwich Integrated Care and Support Collaborative will provide proactive, efficient and effective care to a selected group of individuals with complex needs that is personally tailored for each individual and delivered by a highly functioning, motivated professional and lay team Our aim is to achieve the following by the end of: Year One Team Around the Person Effective working relationships and culture Infrastructure in place Tried and tested systems and processes Service users know who to contact re needs Year Three A significant reduction in hospital & residential care admissions; more early supported discharge and care outside hospital Systems and processes running smoothly High levels of client and staff satisfaction Improved wellbeing compared to controls
Our Plans Phase 2 Greenwich Co-ordinated Care System Focus on high risk patients ( inner city profile) Eltham six month Test & Learn project September 2013 Evaluation April 2014 Roll out across Greenwich July 2014 Engagement and buy-in staff and GP s Behaviour and system changes 3
Practical impact on the care of individuals Early identification Shortest path to most appropriate care Focus on the whole person and family/carer Care close to/in home Easy to refer into and access services Flexibility - people do not get stuck between services. Specialist input in the community
How will we know if we have been successful? 3. Systems, Processes & Pathways 1.Individual Experience 4. Strategic Objectives 2. Staff Experience Evaluation methodologies: Mixed method evaluation including formative evaluation / action learning Use of routine data on health care utilisation compared to non-participants* Data collection on client reported experience and outcomes (wellbeing & clinical)* Staff surveys on culture and work satisfaction* * Support needed with these areas of data collection Year 1 Test and Learn e.g: 1 possible improvements in client satisfaction surveys & I statements compared to baseline 2 baseline staff satisfaction (+/-organisational culture) scores 3 Number of integrated care plans and number of services being used by individuals 4 possible Improvements in selected service utilisation data compared to a control group Year 3 e.g: 1 Significant Improvements in I Statements, client satisfaction and clinical/wellbeing scores 2 Significant improvements in staff survey and organisational culture sore scores 3 Pathways and protocols shared between participating organisations; 4 Significant improvements in services utilisation (emergency admissions, A&E attendance and GP visits) compared to control group 4 Financial balance or better
Better Care Fund ADASS Policy Event 16 th January, 2014
Structure of the Fund 1.9bn NHS funding 1.1bn existing s256 transfer ( 900m today + 200m in 2014/15 130m Carers Breaks 300m CCG Re-ablement 354m capital (inc. 229m DFG) 3.8bn TOTAL
National Conditions Plans to be jointly agreed Protection for Social Care Services (not spending) 7-day Services Data Sharing use of NHS Number Joint approach accountable professional Agreed impact on Acute services Existing s256 conditions incorporated
Metrics National - Admissions to care homes - Effectiveness of re-ablement - Delayed Transfers of Care - Avoidable Em. Admissions - Patient/user experience Local - Agreed selection from the ASC NHS and PH Outcomes
Performance Element April 2015 250m Progress against 4 of National Conditions April 2015 250m Progress local + 2 national metrics October 2015 500m Agreed progress (stretch?) against above
Some Questions What are the issues locally/regionally? What does protecting social services mean? What progress on 7-day working? Can we assist providers reduce income? Is the NHS number achievable?
Integration Policy Issues Adass Policy Event 16 th January 2014
Possible Issues (1) Commissioners JSNA/HWBs/s75/s256 CCGs/NHS future structures Burnham? Beyond BCF not only game in town Future of MH services Care Act Guidance Health Budgets/LTCs
Possible Issues 2 PBR/Tariffs re-inforce Acute Care Better Provider Engagement Foundation Trusts too powerful? Foundation Trust Network links Extent of Competition in NHS Relationship with Monitor stronger?