Integrating Health And Social Care Community Services Richard Milner and Stella Baillie
AGENDA 1. Why we are doing this 2. Our plans for integrating Adult Social Care Assessment and Care Management with Community Nursing and Rehab Services 3. How this supports the CCG agenda for care integration 4. How we can support each other to achieve our shared ambitions for integration and better outcomes for patients and service users Slide 2
WHY ARE WE INTEGRATING HEALTH & SOCIAL CARE SERVICES? Legislation and Government policy Cost and demand pressures across the whole the system of care Ageing population, people are living longer More people are living with chronic long-term health conditions Services are variable and not always well coordinated Overreliance on hospitals and residential care Not enough focus on prevention and early intervention We cannot meet these challenges in isolation We need to work more collaboratively to create the right environment, trusted relationships and leadership GP practices are the mainstay of the local system of care Slide 3
THE BENEFITS OF INTEGRATION FOR PEOPLE WHO USE CARE Vision For Care Integration Establishing borough-specific, integrated, locality-based health and social care services will benefit residents through creating a seamless service that will provide them with health and social care that is co-ordinated, continuous, person-centred and is delivered in or near to their home. Key Outcomes Better coordination of care and improved customer experience Improved support for carers Streamlined functions and increased productivity and capacity Increased choice and personalisation Reduction in avoidable A&E hospital attendances and admissions Reduction in planned hospital admissions and lengths of stay SCOPE OLDER PEOPLE PHYSICAL DISABILITIES LONG-TERM CONDITIONS & COMPLEX CARE Slide 4
PROGRAMME DEIVERY SCOPE AND OUTCOMES Programme Scope ADULT SOCIAL CARE OLDER PEOPLES ASSESSMENT & CARE MANAGEMENT COMMUNITY NURSING & REHAB Programme Delivery Outcomes Joint Tri-Borough and CLCH Leadership Team in place to lead design and implementation of the Strategic Target Operating Model Integrated Community Services teams are aligned to GP Locality structures Community Services staff work alongside in or near to GP practices Community Services are positioned to support the delivery of the CCG Out- Of-Hospital Strategy and Shaping A Healthier Future Integrated roles, establishment of an integrated care coordination function Integrated access points, assessment and referral management Integrated care management processes and systems Slide 5
PROGRAMME DELIVERY MODEL Integrated Programme Delivery Model PHASE 1 OUTCOMES PHASE 2 OUTCOMES Tri-Borough Programme Plan CLCH Programme Plan H&F Locality & Borough Plan RBKC Locality & Borough Plan WCC Locality & Borough Plan Programme Delivery Workstreams 1. Programme Governance 2. Strategic Target Operating Model 3. Integrated Complex Pathway 4. Improving Productivity 5. HR Change Management 6. Organisation Development 7. Engagement & Communication 8. ICT & Telecoms 9. Estates & Facilities 10. Finance & Funding 11. Legal - S113:S75: MOUs 12. Information Governance 13. Programme Management NOV 2012 TO JUN 2013 Phase 1 Integration Plans Signed Off By Cabinets & CLCH Board Tier 1 & 2 Leadership Structure In Place Joint Teams Aligned With GP Locality Structure Start Co-Location Of CLCH & ASC Ops Staff In Network Team Sites Phase 2 Integration Plans Signed Off Joint Operating Agreement & MOUs JUN 2013 TO MAR 2015 Tier 3 Management Structure Appointed & Operational Integrated Strategic Target Operating Model Implemented Full Alignment & Integration With GP Networks and Localities Integrated Teams & Care Assessment Processes & Systems In Operation Integrated Points Of Access Set Up Reduced Demand For Urgent & Complex Care Better Care Outcomes, Greater Satisfaction, More Productivity Slide 6
INTEGRATION PROGRAMME KEY MILESTONES Cabinet and CLCH Board mandate to proceed (DEC 12) CCG Board endorsement of integration plans (JAN 13) Director for Community Health and Social Care, Adults appointed (APR 13) Joint Borough Assistant Directors appointed (MAY 13) Joint Locality Managers appointed and operational (JUN 13) Team structures start to be aligned with CCG Localities (MAY 13) Start co-location of Adult Health & Social Care Teams (MAY 13) Health & Social Care Coordinator roles appointed and operational where possible in each GP Locality/Network - (MAY 13) Strategic Target Operating Model implementation complete (MAR 14) Expected savings delivered by 2014/15 WHAT S ALREADY AGREED WHAT STILL NEEDS TO BE DEFINED Slide 7
STEP 1 STEP 2 SUGGESTED MANAGEMENT & DELIVERY STRUCTURE & PHASING APRIL- MAY 2013 JUNE 2013 CLCH Chief Executive TRI-BOROUGH Executive Director of Adult Social Care Existing Structures CLCH Deputy Chief Executive Tier 1 and 2 Roles Director, Community Health & Social Care, Adults Tier 3 Roles and Team Structures PA To Director Assistant Director Health & ASC H&F Assistant Director Health & ASC K&C Assistant Director Health & ASC - WCC Assistant Director Learning Disabilities Locality Managers Locality Team Structure And Number Of Managers To Be Defined Based On GP Locality and Network Structures Locality Managers Locality Team Structure And Number Of Managers To Be Defined Based On GP Locality and Network Structures Locality Managers Locality Team Structure And Number Of Managers To Be Defined Based On GP Locality and Network Structures H&F Learning Disabilities K&C Learning Disabilities WCC Learning Disabilities Community Independence Manager H&F Community Independence Manager K&C Community Independence Manager Westminster Slide 8
WHAT AN INTEGRATED SYSTEM OF CARE MIGHT LOOK LIKE Empowered people supported at home and in the community to promote maximum independence Responsive high quality care Proactive care based on risk assessment Coordinated care delivered by a financially sustainable multi-disciplinary system to provide quality care at lower cost GP Practice GP Network Named Care Lead Care Coordination Multi-Skilled Home Care Risk Stratification Active Monitoring GP Practice Named Care Lead Care Coordination Multi-Skilled Home Care FAMILY SELF CARE GP Practice Community Care Risk Stratification Active Monitoring Named Care Lead Social Care CARERS PERSONAL CARE NETWORK PERSON CARE AT HOME PERSONALISATION Care Coordination Multi-Skilled Home Care Risk Stratification Mental Health Hospital Care GP Practice Named Care Lead Care Coordination Multi-Skilled Home Care Risk Stratification Active Monitoring COMMUNITY INFORMATION CHOICE & CONTROL Active Monitoring Community Pharmacy GP Practice Named Care Lead Care Coordination GP Practice Multi-Skilled Home Care Named Care Lead Risk Stratification Care Coordination Active Monitoring Multi-Skilled Home Care Risk Stratification Active Monitoring Slide 9
KEY ENABLERS TO A FULLY INTEGRATED SYSTEM OF CARE Leadership And Culture Development Integrated leadership structure Joint organisation development plans Patient/ Service User Engagement Involvement of patients and service users, patients and carers Quality assurance role Joint Decision Making And Accountability Memorandums Of Understanding GP led Locality care system design and operating boards Health and Wellbeing Board oversee whole local system integration Information Sharing Information sharing agreements Co-location of teams to support knowledge and information sharing Aligned Incentives Establishment of joint team bases and integrated care delivery hubs Hot-desking in GP Localities and provider organisation sites Supported With A Shared System Platform IT systems that enable mobile working and co-location Integrated systems that support data sharing and workflow across organisations Shared Facilities Pooled Health & Social Care budgets Aligned performance and outcome framework Slide 10
SUGGESTED TEAM BASE LOCATIONS Our ambition is that Community Health & Social care staff spend more time in GPs Practices AREA REF: TEAM BASE SITES TEAM TOUCH-DOWN SITES WESTMINSTER W1 W2 215 Lisson Grove City Hall, Victoria Street Soho Centre For Health Care KC1 St Charles Hospital Campus Health @ The Stowe 215 Lisson Grove KENSINGTON & CHELSEA & QUEENSPARK Westway Information Centre Colville Health Centre KC2 Chelsea Old Town Hall Abbingdon Health Centre World s End Health Centre HAMMERSMITH & FULHAM HF1 145 King Street - (White City Collaborate Care Centre From 2014) 145 King Street HF2 Parsons Green Health Centre Charing Cross Hospital Slide 11
SUGGESTED TEAM BASE SITES - HAMMERSMITH & FULHAM Slide 12
SUGGESTED TEAM BASE SITES - KENSINGTON & CHELSEA Slide 13
SUGGESTED TEAM BASE SITES - WESTMINSTER Slide 14
PROGRAMME GOVERNANCE HEALTH & WELLBEING BOARDS LBHF Health & Wellbeing Board RBKC Health & Wellbeing Board WCC Health & Wellbeing Board CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST BOARD LBHF CABINET TRI-BOROUGH CABINETS RBKC CABINET WCC CABINET H&FCCG BOARD CCG BOARDS WLCCG BOARD CLCCG BOARD JOINT INTEGRATION BOARD Tri-Borough Executive Director Adult Social Care & CLCH Chief Executive Tri-Borough & CLCH Integrated Health & Social Care Joint Programme Board Tri-Borough & CLCH Integrated Health & Social Care Joint Programme Delivery Group Slide 15
ESTATES PEOPLE OPERATIONAL CCG DEPENDENCIES & IT TOP RISKS & ISSUES TO MANAGE Delay in the appointment or start dates for integrated management structure Loss of key staff and corporate memory during integration Staff do not engage in integration Staff and critical mass of skills too thinly spread across GP Localities and Practices Integrated structures fail to maintain Adult Social Care and CLCH financial controls Conflicting priorities between organisations cost saving priorities (MTFS, CIP, QIPP) Delay or shortfall in expected programme implementation benefits CCGs reprovide community nursing and rehabilitation services Failure to agree Team Base sites Insufficient lead time to fit-out Team Bases and set up IT to support mobile working Not all GPs signed up or engaged with Locality working Points of access and integrated pathways are not universally agreed GPs do not agree the choice and coverage of the proposed team base sites Delays in CCG authorisation and lead time to stabilise changes in the health system Protocols are not agreed to support cross borough boundary working for social care and health staff (e.g. Queenspark, unregistered population) Slide 16
CONCLUSIONS There is a clear mandate across our organisations to proceed and integrate community health and social care services We are seeking to create the right environment, ways of working and leadership that will deliver the step change in outcomes for patients and service users We already have a strong track record of working collaboratively with GPs as providers and commissions to develop, commission and deliver integrated care pathways GPs are the mainstay of primary care delivery and we are aligning our staff and processes to be able to work more collaboratively with GPs to support the successful delivery of the Out-of-Hospital Strategy and transformation of the local system of care Slide 17
NEXT STEPS CCG Board endorsement of Tri-Borough and CLCH integration plans Commitment to sign-up to a Memorandum Of Understanding to work together to develop integrated care pathways and a join-up local system of care Establishment of GP led Locality integrated care design groups with the mandate to take forward joint integration plans Support to enable integrated Community Services Health and Social Care staff to have a greater presence in GP Practices Establish hotdesk space in GP Practices Slide 18