Buckinghamshire Accountable Care System: A collaborative approach to integration Everyone working together so that the people of Buckinghamshire have happy and healthy lives
What is an accountable care system? What it is: Mature partnerships - a coalition committed to collective decision making Partners making a single, consistent set of decisions about how to deploy resources Stronger local relationships and partnership work based on common understanding of local priorities, challenges and next steps A clear system plan and the capacity and capability to execute it Place-based, multi-year plans built around the needs of local populations and local health priorities Delivering improvements What it is not: New statutory bodies or change to existing accountabilities Employers, ways of managing financial or other resources Legally binding (deliverability rests on goodwill, commitment and shared priorities and objectives) Getting rid of the purchaser / provider split or of respective statutory duties and powers Tried and tested. There will be bumps along the way the true test is in the relationships! Removing the need for consensus and collaboration
Our strategy requires system integration Put Care in the Best Place Invest in prevention and early intervention, with increased community services to provide care at home, reducing bed-based care through our Providers, who are working together to make this happen Rebalancing spend over a 5 year period Low dependency levels Current balance of spend Living, Ageing and Staying Well Prevention & Early Intervention Rapid Response & Reablement Future balance of spend Living, Ageing and Staying Well Prevention & Early Intervention High dependency levels Long Term Care Rapid Response & Reablement Long Term Care
Integrating for our population Clusters - 50k population, several GP practices Core integrated team Specialist practitioner team; accessible to more than one cluster, working across primary and secondary care 4
Integrating skills System Practitioner Networks where those with specialist experience in diabetes, COPD, tissue viability, elderly care, paediatrics are accessible to the local population of professionals Our distributive clinical leadership will include clinical health scanners who ensure we have the best outcomes for our population s health and care needs
Integrating for value Current State. Patient with multiple comorbidities referred by GP for hip assessment Future State. Consultant agrees to active treatment; booked for operation Long period of rehabilitation for not much more mobility Patient talks to GP, Community Nurse, carer & family about options & risks of treatment Patient decides not to have operation- weekly bridge and lunch club too important. Management plan includes physio & OT for living safely, pain managed through pharmacist prescriber Health & care services based on outcomes that are important to the service user
Integrating our approach to quality Community integrated team has awareness of level of independence that patient usually enjoys. Patient discharged; 4 week reablement programme to return him to his full pre stay wellness levels Patient admitted for full assessment Shared information enables acute team to understand normal self management All providers working together to achieve the same quality outcomes for patients episode
Integrating technology to support self help Facebook/Twitter to comment real time on health & social provision Personalised Risk Profile On line Health Trainer & FitBit Baby Buddy App Triage, then GP or Nurse appointment
CM: our strong track record of delivery Tangible improvements Dementia INNOVATORS mental health A RATED stroke services 1 st for helping people manage diabetes TOP performers for atrial fibrillation LOW delayed transfers of care BETTER cancer survival rates Better outcomes Your community, Your care : Developing Buckinghamshire together 9
Developing our integration 600,000 contacts cared for outside of hospital annually Working with partners to make health and care services safe, sustainable and able to meet the future needs of our local population Investing over 1m to expand our community services Delivering what patients and clinicians have asked for Helping the people of Buckinghamshire to stay well Through prevention and early-intervention we want to: help patients to take greater control over their care and treatment ensure we meet patients long-term needs to help them to stay independent make it easier to access the right services 10
Developing across the whole of Buckinghamshire Locality teams Rapid response intermediate care Community care coordinators
Community hubs 6 month pilot at Marlow and Thame hospitals Co design with stakeholder group providing a new community assessment and treatment service (frailty assessment service) more outpatient clinics more diagnostic testing working with the voluntary sector
How are patients benefitting? In total c.700 outpatient appointments delivered in community hubs Over 300 people referred, assessed and treated by the community assessment and treatment service at Marlow and Thame Over 1,000 patient referrals managed through the community care coordinator 2645 more care contacts a month by our rapid response and intermediate care team
What have patients said about the service? Overall, how did you rate the treatment you received? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% April/May June July Aug Excellent Good Fair Poor
Key learning Increasing levels of activity and increase in referrals to the frailty assessments service overall Need to continue to raise awareness of the hubs amongst GPs to increase referrals More time required to mobilise and evaluate outpatient clinics and voluntary service involvement Potential to provide more complex treatment locally such as chemotherapy Continue to recruit staff to support the continued expansion of the services Stakeholder engagement group has been an important independent voice Stakeholder engagement group and clinicians have recommended we need to assess performance during winter months Pilot more services in other localities
Proposed next steps Extend the pilot for a further six months Continue to roll out the model for out of hospital care and community hubs: open up access to Amersham, Chalfont and Buckingham to voluntary sector colleagues expand the offer at Thame and Marlow (e.g. ultrasound) explore potential outpatient clinics at our Amersham, Chalfont and Buckingham sites Undertake a second wave of patient, public, staff and GP engagement Final report in March 2018
Fast-tracking the joined-up services everyone wants Your community, Your care : Developing Buckinghamshire together 17
Jean s story Your community, Your care : Developing Buckinghamshire together 18