Embed Size (px)
Citation preview
REPORTItem No: 19
SUBJECT:
TO:
Lead Officerfor Report:
Author(s) ofReport
DATE:
Health&Social Care( ) L j North Lanarkshire
1.
Locality Modelling Implementation Plan
Integration Joint Board
Chief Accountable Officer
Medical Director, Nurse Director
04/01/2017
PURPOSE OF REPORT
This paper is coming to the IJB
2.
For approval x f For endorsement − − To noteThe
IJB approved a paper in November setting the direction for a model of integratedworking at locality level. The paper presented sets out a proposed plan for theimplementation of these changes during 2017/18 with some initial preparation commencingin the remainder of this year.
ROUTE TO THE BOARD
This paper has been:
Prepared By; Reviewed By; Endorsed By;MD& ND, HSCNL
Since the paper describing the locality model was accepted the core group have continuedto meet to write an implementation plan. The group recognises that in order to progressthere are infrastructure issues relating to management arrangements that need to beresolved at an early stage. Some of these issues have been discussed at Strategic leadershipteam but will require further discussion and option appraisal before solutions can be arrivedat. The implementation plan sets out the steps required to manage the transition to the newmodel of care.
3. RECOMMENDATIONS
3.1 That IJB approve the implementation plan as set out in the attached documents andask the locality modelling group to continue to progress towards implementation ofthe model along timelines suggested here.
4. BACKGROUND/SUMMARY OF KEY ISSUES
The Strategic Plan for the IJB is based around services delivered in localities. Localitymodelling has been a significant workstream during the planning for integration and will becentral to the Strategic Commissioning Plan for 2017. The paper noted at the liB inNovember set out a broad overview of the locality, the services that will be directlymanaged within it, and the principles that will govern locality working. The IJB endorsed thisapproach and asked for a further updates specifically outlining the implementation plan andassociated timescales. The paper presented in November is attached as an Appendix.
S. CONCLUSIONS
Implementation of the locality model is a key component of the strategic commissioningplan and an important step towards delivering the benefits of integration. Thisimplementation plan sets out key milestones for implementation to be followed in thecoming year.
6. IMPLICATIONS
6.1 NATIONAL OUTCOMESAll national outcomes will be affected by the way we set up and manage our locality basedcommunity services. Successful implementation of the model will deliver benefits across thenational outcomes.
6.2 ASSOCIATED MEASURE(S)These are outlined in appendix 1 but further work will also be undertaken to set outmeasures for the LHSWTs as they form.
6.3 FINANCIALThis paper has been reviewed by Finance:
Yes NoShould
be reviewed prior to IJB. Some of the steps in the implementation plan will bedependent on securing resources. The early steps relating to unification of the LHSWTs inlocalities are not immediately resource dependent but it is highly likely that they will quicklyidentify gaps in service that cannot be filled without investment.
6.4 PEOPLEThere are significant workforce implications for staff within this paper. The paper highlightsthe need for partnership approach with human resource support as we move towardschanges in management arrangements and team structures.
6.5 INEQUALITIESEQIA Completed:
No L i IN/A x
7. BACKGROUND PAPERS
As attached
8. APPENDICESLocality Modelling paper − IJB November 2016
.............................................................................CHIEF ACCOUNTABLE OFFICER (or Depute)
Members seeking further information about any aspect of this report, please contact AnneArmstrong on telephone number 01698 858116
kAM:—z ; Health&SociaI CareNorth Lanarkshire
Progress in development of North Lanarkshire Locality Model
AIM
saferhealthierindependentlives
The North Lanarkshire Locality Model is a model of working for integrated health, social care andother relevant services based in localities that best serves the population of that locality. This papersets out definitions and principles around which that model is based and describes the proposeddevelopment of integrated Locality Health and Social Work Teams as−a part of that model
LOCALITIES
Localities are discrete geographical areas around X'hich many public services a ' ! a n n e d andorganised It is the intention of Health,−and Social Care legislationthat localities play 'n increasingrole as services and supports i n t e g r a n North Lanarkshire there are six well established localitiesteNthat
are largely centred on the main towils but include surr1nding areas In most cases the serviceand supports that an individual will expect to access if they require"a health or social care input willbe determined by the locality in which they live
The needs of a localiti.bpulatioft.ateam as described in this paper willall the functions that are needed wi
The locahty is made 'u of a numberprovide services and supports to thiinclude integrated health and socialcriminal justice services, third sectocare or specialist services serving thother services such as education leappropriate informatihaririár
PRINCIPLES
re diverse Sbo,cidoplex. AnThtegrated Health and Social Workbe a key component of a locality model but cannot encompassthin a locality to serve that population
of teams, services and people that are linked together to;se that live within its geographical boundaries A locality willwork teams practice teams including GPs, children's services,r orgàriisätions, independent sector providers and also secondary
e locality. The locality concept is fluid and allows inclusion of
sure, police etc where it is appropriate to do so, providedangements are in place
• The prime purpose of the locality is to help the people in that locality live safer, healthier,independent lives.
• Prevention, early intervention and self management are promoted and supported within thelocality.
• Where support or treatment is required this will be person centred, drawing on the differentparts of the locality supports and services required by the individual.
• All parts of the locality will deliver supports and services that are safe, effective and timely.
• The locality is designed to ensure that where needs are identified then individuals can accessthe supports or service best suited to those needs through a single gateway.
• There is "no wrong door" to the locality. If somebody enters the system but are assessed asrequiring information, advice, a support or service delivered by a different team within thelocality they will be able to access the support or service that can best meet their needs with
no additional barriers.
FUNCTIONS OF LOCALITY MANAGED SERVICES
The services directly managed within localities need to be designed to fulfil the following functions:
In all cases these functions refer to physical or mental health or sp'ci!. care needs for people of all
ages within the locality
Screening, prevention and the promotion of improved health and well being for the wholepopulation with a focus on reducing inequality. This includes intenve a,alysis of needs within thelocality, health promotion, welfare rights support nd linkages to comminty education, leisure andother relevant services./
Rapid response (low level) People that require rapid advice support or low level intervention todeal with an immediate or emerging issue The development of technology enabled"are will beimportant both for this group and for those with more complex needs
Rapid response (more complex) that People that require a more crnplex intervention to help them
manage a situation This i 1 l c u d e prevention of admission and facilitation of early discharge fromhospital in many c a s e ' '
Targeted support andthis to include.:c.hIl1, adult
Management of long terc h o i c ë ' d control throu
R e h a b i l i t a t i n d / o r Rea
Palliative or end
MANAGED TEAMS PART OF A LOCALITY
• Locality Health and SOcial Work Team (see next section)
• Locality Child Health and Social Work Team (health visitors, children's social work, children's
nurses, community paediatrics)
• Locality Mental Health Team (CMHT, ECMHT, psych therapies team, Mental Health Officers)
• Locality Addiction team
interventions for at risk groups within the locality population,publicrötection functiOns.
nditióhs over prolonged periods of time, this to include promotingD i é d Support.
t.followiiig'an illness or injury.
care for thOse that need it
All these teams would over time be managed by the locality management team, the core of whichcurrently comprises a Health and Social Work Manager who directly line manages two Locality SocialWork Managers, one for Children Families and Justice, the other for Adult Community Care, and aHealth Service Manager.
LOCALITY HEALTH AND SOCIAL WORK TEAM
The Locality Health and Social Work Team (LHSWT) is an integrated team comprising
As a minimum the integrated team will comprise of district nursing, allied health professionalsworking in the locality, locality social work staff and home support staff with the scope to extendthose staff groups depending on the needs and resources available within the locality.
GPs and other practice−employed staff will be incorporated in the "team" surrounding eachindividual patient, liaising closely with all disciplines in the LHSWT. The team will therefore broadenthe range of competencies available within the locality as part of an extended Primary Care Team.Locality lead GPs will have a key role in guiding the developmentof these teams and their
interaction with GPs and practice employed staff as well as providing clinical guidance in thedevelopment of operational policies In time it is likely that the teams will have dedicated medicalinput.
The team will provide assessment rapid response and longer term care management of adults of all
ages in the locality who have identified health and/or social care needs that require assessment and
support or intervention There will be a single gateway to the LHSWT People entering the servicethrough multiple access points such as their GP practice, via Makin' Life Easier, Sddil,,Work Accessteam, and Fast track or referred fromgateway
and first assessment will therindividual's needs. As outlined in the pif initial assessmentthen there will be raEmergency Departnto developing person
and GPs't
cf.c plans
In due cou'é'1'HSMTs will ab'brS., \ \
services that outreachtrom hospi
one Ô i l a l i t i es reach iniothe
er tea
I or other
9Jp by the eiidsfherê:will be "n
ry care service will pass through thatIappropriate professional for thatS o n g door" to locality services andd r meet that individual's needs
service In addition the team will proactively engage withentify patient regularly utilising unscheduled care with a viewbetter meat their requirements.
rô is currently offered by Hospital at Home, CARS and othermoving us from a model that sees the hospital reaching out to
k l and maintaining a degree of responsibility for peoplefrom th&1661ity wherever fh happei ôbe in the system.
Specifically thè'téàm will
The team's ethos Willkbe to. port and enable independence enabling people to maintainresponsibility for their i i f h and wellbeing for as long as possible. Interventions will rangefrom simple sign posting af?'advice to complex assessment and care. This will be driven by theneeds of individuals accessing the service ensuring any subsequent interventions are designed tomeet their needs and aspirations promoting independence and personal responsibility.
Assessment −an assessment forms the cornerstone of effective intervention and will be undertakenby the most relevant professional, this may be a simple assessment or a fuller, comprehensiveassessment.
Locality Response − a rapid response that can be deployed to support GPs or other parts of thelocality that offers assessment and can within hours set up support and care for a short period toallow a person to return to normal activities as soon as possible, the aim being to avoid progression
to higher level interventions including hospital admission. Consideration should be given to thisteam having a "gatekeeping" role in the locality, with all decisions about admission needing to beagreed with the team before a bed is accessed.
Discharge support—The team will be aware of all people from the locality who have been admittedto hospital and will pro−actively engage with hospital teams to pull people back to their communities
as soon as it safe to do so. If a need for support, care or treatment on discharge is identified theteam will have the authority to set this up on the same day and/or make appropriate links orsignposts.
Rehabilitation and Reablement— after a period of illness or injury people will frequently requiresupport to enable them to reach their maximum potential. This ,ftintion will sit within the LHSWTs.
Care management of people with complex needs— Some pebpié' i th long term health conditions ormulti morbidity require ongoing monitoring and support to preven exacerbations Care for suchindividuals should be managed in a multidisciplinary team with clear communication within andbetween teams involved in the individual's care The LHSWT will take the lead in care managementwhere there is an identified need for this but will work in partnership with locality mental health oraddiction teams where there are co−morbidities. PrOäctively data:isuch as SPARA ill be utilised toidentify individuals frequently utilisingunscheduIed care Services with a view to working with themto improve their health and wellbeing retlucing their reliance on unscheduled care servicesAdditionally as part of the prevention agenda, appropriate links or signposts will be made toappropriate community supports
There will be elementHours hub services iI
proportionate to asseshours of locaIit.yservices
service lilGocavaiIblé
ed to beneed at
at will be:tq)lored toftimes. Thereiisbuttha
H o e Supm o
red'o function 2 4 7 and the links to Out ofthere is a Iè 1 of service available
Ill be scope to explore a model that extends thebrough the night a North Lanarkshire wideandcommunity nursing out of hours would be
Once thé'iiéèds of the persóhave redCIêdto the level that the LHSWT is no longer required thenexpectation'wold be that the i1ctice team would resume their role as main point of contact if the
person has f u r t } 4 e d s . Tranit'iOns in support and care between teams will be smooth and joined
up with the individ6l,being part he discussion with the LHSWT and Practice Team
IMPACT
It is essential that in fulfilling the team functions described earlier each Locality is able to track theirimpact in achieving the national outcomes. This will enable data to be used to achieve continuousimprovement ensuring that support and care meets the needs of local people. A performance datawill be further developed with the H&SW Managers.
NEXT STEPS
The model described here has been agreed with key stakeholders so next step is to scope out theimplications for each Locality in terms of workforce capacity and capability. This will form the
Locality Model Implementation Plan (Paper 2) which will be prepared for January 2017. This planwill be reviewed and refreshed on a 6 monthly basis.
CONCLUSION
The model described here has been developed with wide consultation and builds on work that hasbeen in progress for at least three years in North Lanarkshire. The paper prepares the ground for thepartnership to move towards implementation of the integrated Health and Social Work teams thatwill be a key objective of the Strategic Commissioning Plan for 2017/18.
There is a need to ensure any anomalies that currently exist around differences in boundariesbetween health and social work services are resolved as early as pssible in the integration process.
There is considerable data available about each locality throuh±hè locality profiles and otherinformation held by locality services This data should be used to help inform a workforce modelthat could meet the anticipated demands in each locality If, as seems inevitable, there is a mismatchof capacity and demand then priorities for investment would need to bedentified to try and
increase capacity where this will deliver the gre'ates impact, maintaining partnership'scommitment to its agreed priorities
As we move towards implementatioirequirement for Practise Developmeto implement the changes within te
Alast
ng needs aiäIysioisational De−V.4'..
it WAll.take place.
be required and tilélé will be aent and Human Resource support
mpson.::.::
Appendix 1
The National Outcomes
Outcome 1: People are able to look after and improve their own health and wellbeing and live ingood health for longer
Outcome 2: People, including those with disabilities or long term conditions, or who are frail, areable to live, as far as reasonably practicable, independently and at home or in a homely setting intheir community
Outcome 3: People who use health and social care services have positive experiences of thoseservices, and have their dignity respected
Outcome 4: Health and social care services are centred on helping to maintain or improve thequality of life of people who use those services
Outcome 5: Health and social care services contribute to reducing health inequalities
Outcome 6: People who provide unpaid care are supported to look after their own health andwellbeing, including reducing any negative impact of their caring role on their own health andwell−being
Outcome 7: People using health and social care services are safe from harm
Outcome 8: People who work in health and social care services feel engaged with the work they doand are supported to continuously improve the information, support, care and treatment theyprovide
Outcome 9: Resources are used effectively and efficiently in the provision of health and social careservices
3f
(DC
D0
—cr
o−
40
CD
CD0
3r
CD
°3
(f
l3
.,0
_.
CD
0(
DC
D0
.uc
l−D
—'
rD m7
rO−
CD
1−.
aC
DtD
00
0C
D
I>0
00)
I.m
−.=
−0)
−e
D10
CD
CD00
3—'
32
CD
3 CD
0C
D crC
D0
CD
0C
LLn
Ln0)
0o
D 0−D
—C
Dcu
CD0 —
'00
CDCD
CD
C,0)
0)F;
lC
LC
L0
.0
000
Ln00
CDC
D—
t.—
zOC
DCL
0.
—3−
93I
01CD
('I
(lCL
rDC
C.,
—.
rD− −<
•0)
0—
'—'
CD
o(1
(I)
CDCD
CD
−p
CDCD
CD
C− CD3
33
−'c
rC−
C−CD
CDC
D1(
0−4
.J
•.
••
..
.S
SS
SS
•
a—
C−)
(/
>(F
)0
(10
CDrn
0.−
(D
3C
D0
CD
)(5)
_•
(0
c3
0(0
CD0
.D
0.
20
−C
T=
0<
oj0
o=
CD
—C−
<O
0LA
jC
)C
D0
rD<
CD(D
CL
DC
DCD
00
.0
.0
.CD
0−
s,−D
0−
<C
D10
aq0
CD
0)
o−0
0"
no
0CD
In'−'
0.'
2.CD
0—
CD0
CD
—CD
CDIe
P 1(0
CD
.<
(0T
0.
−'(n
CL
CD0
..p
Qj
30
—
.PO
C)
C(1Q
V)CD
3−<
0.c−
−0
)(5
)−<
rD3
30.
0)01−4
,—.
(I)0)
P0
CD
3(0
3(5)
(5)C
,cu
−'0.
0.
,.p
P
—'
03
05
<−p 0
CD(
D.
<C
DCD
0)CD
CD
CA
0.0.
3rD
')0
.C
D
x
30−
CD0
—rD,
+C
D1
(b
CD
°D
oCD
0(D
35
32−
CD
,−P
CD
Do
rDCD
00D
o0(/
o3−
CD−
CDCLLn
−:(n
3..
−Ln
C.)
0DCD
DoC
kC
DQ
CD
Z3
.−o
CD=
rCL
0−
CD
)CD
=r
CD
−−
CCL
rD
<0
5
Do
ro
CDD
o
CD3
0−<
−'a
g0 r
CD77
−$'
—3
.,
.C
D0
Do30
I)j
0
=3L
n5
3I
C.)
CD0 3
2:z
0−
CDc
Do−
D5
CDCD
0)D
oCD
—−3 a)
−.3
(D(D
32:
9.CD
CD
ZI
II
II
1>
<C
D<
Do
−'a
wa
aai
CDC
D1
0)
CD
−,
CD
CD
CD
CD
CD
WC
ACD
C.)CD
—C.)
0−
0−
0−
0−
0−
0−0)
rD'−
'oj
−−
DQ
O0
00
00
00
IA−
'CD
D−
'—
.−
"−"
33
+3
'−
fl
IC
)I
CD
CDC
D0
CD0
0C
D0
CD
z
−'g3
33.−
tU
pCD
.−t
−'
−3C
D
rD0
o−3 a)
a
−−
−'0
(0CD
CD
CD0−
CD
Z0
ZZ
LnZ
0C
)0
0CD
0<
<−−
CD0
CDCD
CDCDc
r3
CD3
33
3−
'0
Dc−CD
CDm
CDC
D 1
,−I−•
SS
SS
••
•.
•.
.S
33
=o
8=
H11
CD0
−−(D
B−
0−
0D
q0
ao
3−
−a)
−'
CDCL
−0rD
33
CD
'a)−
0)0
C)
Q_0
)−
f<
CD
n(
D,
,O
CD
CD−
00
0−CD
CD<
CD
−<
CD
−.
0−
.C
Dx
CD
a−
.
(n
=r
CC
DV
)0
)(
IQ
)C
DC
D0
=0
Do5
00
a3
−0−
CL−
_3−
−0
0D
.. −s77
CD−
tCD
....
.o−
−I,
−P
.−
3_1
00
−I
2,
CD
C)
0<<
0−P
C)0
00
0−
0C
)orD
C.)C.)
30'
CDCD
−i−'
−$3
C.)
0)CD
(DCD
3fDC
DC.
)0
.
CD(
0)0
CD0
0−" CD
=
0)−D
cCD
00−
0C) 1
−<
3D
CD
rD('3
aC
D0
.0
.2
L−
<CD
CDo3
DC
D0.
.<CD
−.
0Ln
−C
D3
−co
0C
DQ
..CD
rD=
r0
−p0
0.3
,−v
−v
,..p
−'
<−
−>
0.−
Pa
)−
'3
CD
CD
−DO
I0
00
r'
CD0.
.1,
0−
''
CD
Q−
QU
'CD
Q)D
.2
a)
(a
)C
DO
rD0
U'
a)C)
CDrD
M..f•,
Da
)3
−'−
CD−
o'
°a)
C)CD
.Ln
cu0_
CDa)
CD
0'
D.
3U
'0−
n,−n
CD3
c3
<C
Dq
LA
.P
<−
(,
Oa
)4
.p
CD
>a)
U'
Pr
,−
.o
cr
,0
CD
0C
D0
−0
C)
wJ
gD
'Q
.N
J'r
rCD
CDC
D3
oo3
<10
rD
03
0−
,CD
CD
Q.
−0
.CD
U'
0.
−C
)a)
0.
CD
CD
−'a)
0C
U−
−CD
−0
0'
.0
CDCD
CDC
,.−
pa)
_c
30
.3
0a)−
p.
co
oa
j'
−j
0U'
a)_
.0
.0
0.
.0
CD
a)
−−
Po
3U
'U
'−−
r0
r,(
CDCD
a)−
U'
−p
=ca
c−
SD
.z
−a
)3
a)
U'
>(
CD
o=5 Q
OC)
0
2−
o3
I
Hi
l(
/)r−
c3>
r'
iz
CDCD
>0
−.
()
)(
cC
Da
)a
)L
nr
ICD
cCD
0.
0.
CD0
.C
)C
Dc
CD
OQ
.<C
(.nC
D<
CDR C
D
a)
0.
CDC
)−0 rD
U'
0
w−'
zC
Da
)c
O−
<0.
2.C
D
V('−
3>
0CD
CD0
CD
C)
a)
CDC
)
CDC
D3
3co
00
CD
−3
−1−
•
S•
•S
••
SS
I•
S•
S•
•S
3r
nC
)>
a)
cCD
CDCD
a)
cc
CDCD
CDCD
CDCD
CDC
D3
−rD0.
0o
0.
0.
0.
Cl
0.
0.
−'
0.
0.c
cc
cc
cU
'C
Dcc
00
.,
r,
C)C)
C)C)
a)C
)C)
<C
DU
'−
.C
D−
'0
.C
DC
DC
DC
DCD
CDCD
CD(n
CD
CD
Oa
.0
.0
.0
.0
.0
.0
.0
.0
.CD
0.
0.−
.D
.Ia)
oZ
oU
'C
a)
a)
.−p
(I)
CDU
'CD
U'
CDC
U'
CD
CW
−−
−−
−0
.−
w0
=30
0=
330
−,.p
7SCD
QCD
(I)
0.
0.
0.
0.
2c0r
Daq
U'
−−
U'
CD−
C)
a)
C)a)
a)a)
a)C
)C
D3
CD
a)
(−
3w
(D
.C
DD.
CDD.
CDQ
D.C
Do
CDr
3o
−'−
II
,C
D3
C3
cc
<a
3c
L−
_•
>•:
0w
3CD
U'U
'
−−
c0
00
0CD
CDCD
CD
0.
2.
U'
0.
"0
.U
'0
.−
5U
'0.
(/
.a
)−
<C
Ca)
cc
.0 3
CDCD
CDC
DCD
−P.
0.
0.
0.
−'
0.−S
C)
C)
C)
a)a)
a)a)
−,C
LCD
CDCD
CD
CD−<
CD
0 0 0 −I.Q
L'I) 0 (b (1
)
LArn
(D
n3=
rDQ
)−−−
%0
3.
CDrD
CL
—(I, =
CDCD
CD−
−rD
CT)
CD
CD
2.(I3
0Q
)C
D0
00
6−
CDC
LCD
−.
−C
)C
DC
DCD
p−P
00−.
oCD
3(1
W)
−.
3r
0rD
3C
=C
DC
D3
CD
CD
O
−C
)C
DQ
aCD
rD77
(JC',
=0
OC
)—
CDo
CDQ
)C
) CD
3 −.
−n1•
0)=3
1+0)
3−
pQ
)•L
no
CD
oC
D:
2.
('C−'
fOuq
CD0)
CD.−
*FD
*0)
0)
0)0
0..
0'C
=r
Q)
CD−
n
0)0) 00
CDC
D−'
CD
>>
20..
CL
==
(CC
.')rD
CD
C)C
D−4
.C
/)
0)
0)
0)−C
−CC
)C
)C
)
00
00
CO
••
..
..
•
)−−−−
5•
=000
−'−'
CDC
DCD
CD
CD0)
CO
O)
5
V)
C)
VC
)(
AC
DC
OC
DC
D0
CD
CDC
D
a)
Q/'Q
)QCM
CM
CL
CL
CD0)
C)
C)
C)
31
o0
(D
03D
=3rD
CLo
−4−−
C
−+0)
−4.
OC
DO
)−'
−C3
CD
CDCD
−CD
CD
oo
Ln
0.
