Healthy Lives Healthy Futures NLAG Trust Board

Tuesday 26th May 2015

Out of Hospital

Area of clinical focus

In Hospital

Fully engaged public and patientsG

ener

alis

tSp

ecia

list

OUT OF HOSPITAL

IN HOSPITAL

PLANNED CAREUNPLANNED CARE

CHILDREN & FAMILIES

LONG TERM CONDITIONS

END OF LIFE CARE

Workforce

Planning &

Organisational

Development

Quality and

Outcomes

Information

TechnologyEstates,

facilities, transport

Finance and

Contracting

Clinical and

Public Health

Engagement

HLHF Key Work Streams – Clinical Focus

HLHF Definitive List of Schemes NLAG

Advanced Community Teams NEL Endoscopy Integrated Locality Teams NLAmbulatory Care Service NL ENT Max Fax Service Review

Assisted Living Centre NEL & NLFEAST (Frail and Elderly Assessment Support Team - Scunthorpe)including Integrated Discharge Team Ophthalmology

Breast Services Review Frail and Elderly Assessment Unit (Grimsby) RATL (Rapid Assessment Time Limited Service)Cardiology CDCU (Grimsby) Goole HLHF - Campus Reduction in review Outpatients (NL & NEL)Cardiology Review - Phase 2 Goole HLHF - Elective Respiratory Review - Phase 2Childrens Surgery Goole HLHF - Medicine Inpt beds Stroke Review - Phase 2Critical Care Strategy - Phase 1 Goole HLHF - MIU Urgent Care ServicesDermatology NEL & NL Haematology/oncology Site Potential (All)

NL NEL7 Day hospital social work team NL End of Life ServicesCare Home Liaison Service NL Extra Care HousingCarers Support NL Frequent Service UsersChronic Wound NL GP Front EndingDiabetes (Super 6)NL Home from Home NELDischarge to Assess NL Single Point of Access (H&SC)LTC Model Support into Nursing & Residential Care HomesMSK  Older Peoples Mental Health Liaison NL  Wellbeing Hubs NL  

Year One – Draft Implementation Timeline

Name of Scheme 2014-15

Year 1 ImplementationYear 2

2016-17Qtr 1 Qtr 2 Qtr 3 Qtr 4Advanced Community Teams - NEL Ambulatory Care Service – NL Assisted Living Centre Breast Services Review Cardiology Day Case Unit Cardiology Review - Phase 2 Childrens Surgery Critical Care Strategy - Phase 1 Dermatology Diabetes / Super 6 – NL Discharge to Assess – NL Endoscopy ENT Extra Care Housing FEAST Goole HLHF – Campus Goole HLHF – Elective Goole HLHF - Medicine Inpt beds Haematology/Oncology Home from Home – NEL Integrated Locality Teams – NL RATL (Rapid Assessment Time Limited Service)

Primary Care

Practitioners

Proactive Care

Community

Health and

Social CarePrevention, &

supporte

d

self care

Falls

PreventionMental Health

Health Promotion

Out of

Hours

End of

Life CarePodiatry

Continence

Carer

Support

Hospitals and

Care HomesRapid Response

Day

Supp

ort

Care

and

Reha

bilit

ation

Supp

ort f

or

Inde

pend

enc

e an

d Is

olati

on

Enab

lemen

t an

d Re-

ablem

ent

Assistive

Technology

FamilyCa

rer

Community

Drug and Alco

hol service

s

Single

Point

Access

Community Hubs are the first order of transformation

WHAT

A range of health and care professionals working together to meet all of the health and care needs of their residents

Actively liaising with professionals where onward referral for specialist support is needed

HOW

Doctors (family health and medical), Nurses, Social Care, AHPs and Pharmacists

Working from health and care facilities integral to the Hub

Accountable for outcomes and funding across all settings in an outside the ‘Hub’

Next steps

Create outcomes framework with KPIs – Quality, Money and Activity – by end June

Progress implementation of the transformation schemes for 2015/16, including Better Care Fund Schemes - ongoing

Produce the Operating Framework for Community Hubs via Clinical Leaders Group – by end July

Develop the pipeline of additional out of hospital schemes aligned with Hubs - through summer