Document

Report
Health and Care Integration
Tom Shakespeare
Policy Adviser – Health and Social Care Integration
Local Government Association
December 2013
The future is ….
Devolved
Personal
Local
Different
Integrated
Key issues to address
SCOPE
How best to
protect social care
to benefit health?
OUTCOMES
Who will benefit
and how will we
prove they have?
SERVICES
How will services
change to deliver
sustainably?
REWARD
How to secure and
share the whole
fund?
Building on existing strengths
SCOPE
Identifying people
at greatest risk of
hospital admission
OUTCOMES
Joint Commissioning
to deliver better
results
SERVICES
Re-ablement to
keep people at
home
REWARDS
CQUINN, QOF, new
contract models to
incentivise providers
The real challenges
SHARING
INFORMATION
to plan and deliver
intelligently
SHARING MONEY
to commission for
individuals across
services
SHARING STAFF
to enable best
use of skill and
resources
SHARING RISK
to maximise shared
gain and mitigate
shared losses
BCF Plan requirements?
Metrics
Ambition
Population in scope
Health outcomes
Total CCG spend
Wellbeing outcomes
Total social care spend
Choice and control
Pooled budget
Resource shifts
Conditions
Performance
Jointly signed off

Emergency admissions
Protects social care

Effective re-ablement
Data sharing

Delayed transfers
7 day working

Accountable professional

Residential and nursing
care admissions
Impact on acute hospitals

User experience
Risk sharing agreement

Local Priority
2014/15
2015/16
2014/15
2015/16
Next steps
FEBRUARY 2014
Agree ITF Plan setting whole system goals,
allocations and service levels, setting the ground for
delivery in 14/15 and 15/16
SEPTEMBER 2014
Ensure delivery of the national conditions (protection of social
care, data sharing, 7 day working, accountable professional, risk
sharing, acute sector implications) and baseline performance.
SEPTEMBER 2015
Ensure delivery of agreed performance goals to secure full payment of the
ITF in 2015/16. Confirm delivery of national conditions and local whole
system changes.
Is there any
support
available?
Whole System Integrated Care
Support Products – Toolkit and National Database
National
database
Local
value
cases
Modelling
1. What are good examples of different models of integrated care?
2. How do you commission integrated care?
3. What are the service provision options for delivering integrated care?
4. What information is there on the strategy behind integrated care?
5. How can policy help or hinder integration?
6. What are the financial implications of integrated care?
7. What are the information system requirements / options to support integrated care?
8. What does the evaluation of integrated care show?
1. Case Studies
2. Commissioning
3. Service Provision
4. Strategy
5. Policy
6. Finance
7. Systems
8. Evaluation
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Workforce Integration
Patient Engagement
National Standards
Marketing
Comms & Stakeholder
Engagement
Technology
Leadership
OD
IT System
Ways of Working
Technology for integration
Evidence review
Personal Health Records
Evaluation
Patient Experience
Data and Analysis Tools
Measurement of Integration
Financial Modelling
Service Design
Teleheatlh/care
Workforce
Self Management
LESSONS LEARNED:
Risk Stratification
Stakeholder Engagement
Data sharing and information
governance
Policy
Strategy
Person Centred Care
Mental Health
Long Term Conditions
Finance
Evidence Review
Elderly
Service Provision
Commisioning
Technology
OD
Training & Comms
Resource Allocation
Patient Engagement
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Copyright ©2013 Integrating Care & the Local Government Association
Workforce Integration
Benefits of integration
Lessons Learnt
TAB
Case Studies
KEY QUESTIONS
Case for Change
INCLUDES THE FOLLOWING ELEMENTS:
Outcomes
Overall
value case
Governance
Building the
case for change
National
evidence
review
Financial Barriers
Evidencing
Collaborative working
Integration
toolkit
Signposting
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Whole System Integrated Care
Support Products – Local Value Cases
Signposting
Integration
toolkit
Local
value
cases
Evidencing
Building the
case for change
National
database
Overall
value case
National
evidence
review
Modelling
Copyright ©2013 Integrating Care & the Local Government Association
Whole System Integrated Care
Support Products – National Evidence Review
Signposting
Integration
toolkit
Local
value
cases
Evidencing
Building the
case for change
National
database
Overall
value case
National
evidence
review
Modelling
Copyright ©2013 Integrating Care & the Local Government Association
Whole System Integrated Care
Support Products - Modelling
Signposting
Integration
toolkit
Local
value
cases
Evidencing
Building the
case for change
National
database
Overall
value case
National
evidence
review
Modelling
Copyright ©2013 Integrating Care & the Local Government Association
Whole System Integrated Care
Support Products – Overall Value Case
Signposting
Integration
toolkit
Local
value
cases
Evidencing
Building the
case for change
National
database
Overall
value case
National
evidence
review
Modelling
describing outcomes for individuals
a single care plan
co-ordinated with individuals and carers
“I have access to the support and
expertise to keep my patients well”
“Taken together, my care and support help me
live the life I want to the best of my ability”
describing outcomes for communities
effective risk-stratification
targeted information sharing
“we are able to target local resources to
maximise independence and wellbeing”
“The professionals involved with my care talk to
each other. We all work as a team.”
describing outcomes for the health economy
Copyright ©2013 Integrating Care & the Local Government Association
increased prevention
reduced acute demand
“through delivering better care we have
been able to keep people out of hospital”
“we have managed to reduce the pressures on
health and care budgets to manageable levels”
Whole System Integrated Care
Support Products – Model ITF
Who are we focussing
on: name, age, personal
circumstances,
capabilities and needs
1. Persona
2. Vision
5 year vision
2 year vision
1 year vision
3. Outcomes
5 year
4. Schemes
5. National Conditions
Copyright ©2013 Integrating Care & the Local Government Association
2 year
1 year
What is the vision for how
that individual and the
community, acute,
primary and social care
services that support
them will change over 5,
When
that vision is
2,
1 years?
delivered, what are the
likely outcomes and
what is our ambition in
terms of key
How do current
performance
approaches and
measures?
proposed changes map
against the vision and
outcomes, and what if
any are the gaps?
How will these changes
affect the 4 national
conditions. What are the
risks involved and how
will we manage these?
Completing the ITF:
Focusing on Needs
Copyright ©2013 Integrating Care & the Local Government Association
Mrs Patel, April and Les each have a single
care plan and have been provided with simple
devices and support that allow all three of them
to self-manage their conditions on a daily
basis. With clearer information and advice, and
knowing professional support is there if the
need it, they feel in control of their lives.
Mrs Patel is part of the ‘Shared lives’
scheme and she regularly visits with
her ‘adopted’ family who share her
cultural background and enjoy
spending time together. Les and April
are linked into local voluntary
schemes for older people
which allow sharing of
I feel part of
experiences and for
a community
mutual support.
Completing the ITF:
Our Vision
My health
conditions are
under control
Mrs Patel and April both have a
named GP and someone from the
surgery co-ordinates all the different
services within their joint
Care plan. A single
The care
patient and care record
I receive is
which they can access
built around me
and control is used by their
clinicians and care workers to ensure
they only have to tell their story
once. They know they will have
continuity of care and support, seven
days a week, even if they need to go
I am supported
into hospital for a short spell.
through difficult times
When circumstances change, Les,
April and Mrs Patel are pro-actively
contacted to re-assess their needs.
Their care co-ordinator is proactive in
ensuring that support is available to
them within their communities,
through difficult times.
Copyright ©2013 Integrating Care & the Local Government Association
Specialists are on hand to help identify potential
mental health issues and provide specialist
advice and guidance as part of overall care
planning. Mrs Patel, Les and April all receive
support in their communities, including
through local community groups,
to help them stay fit and well.
I am treated as an
Individual and helped to
stay well
April’s home was adapted with a stair
lift and various simple aids around the
home she is now at much less risk of
falling. She has chosen her care home
for when her dementia progresses and
has a choice of local providers
I live safely and
who are there to provide
well, where I
the very environment for
want to be
her care.
The community independence team
(a team including community nurses,
OT’s, geriatricians ) provided
both preventative care and
My
planned support to April
independence is
before and after her hospital
respected
stay, all helping her quickly
to get back on her feet.
Her GP was involved even whilst she
was in hospital in supporting support
April’s care and ultimate discharge
My neighbours are
back into the community.
able to help me
The local community organisations
are able to provide lifts to take April
and Mrs Patel shopping once a week
and ensure that they were
accompanied to get back and for to
hospital / GP appointments. Local
shops and services play their part.
Completing the ITF:
Lessons Learned
•
Engagement and Leadership
The ITF process is an opportunity to
describe the reality that you want service
users and patients to experience
•
Build on what exists
This is about understanding how current
initiatives relate to each other to deliver
outcomes, and which are the most
important – it is not about starting from
scratch
•
The ITF is a map towards a vision – it is
a practical tool with real local benefit
The ITF brings stakeholders together to
have honest conversations about what
needs to happen in local service
provision to deliver a vision for the
future, based around concrete funding
commitments
Copyright ©2013 Integrating Care & the Local Government Association

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