Integrated Care: Integrated Community Services

for AdultsCath Doman

Head of Community Health CommissioningProgramme Lead Integrated CareNHS Airedale, Bradford and Leeds

Lyn SowrayAssistant Director

Adult and Community ServicesBradford Metropolitan District Council

Integrated care programme

• Delivering the vision for integration

• Transformation of health + social care in the District

• Integration of community services clustered around GP practice/s

• Services working as a single team for each locality

• Risk stratification of locality population

…whatever the person needs following (or to prevent) acute care or long-term dependence

• Reablement• Rehab• Recuperation• Return to optimal health + wellbeing

In simple terms, it’s…

The vision

Right careright placefirst time

Joined up services to enable people to regain and keep their optimal health, well-

being and independence

The health economy• Need for new models of care delivery

– Funding gap– Shift from hospital to community requires greater

capacity and productivity in community services– Growing demand/population requires a preventative

approach– Increased capacity to prevent needs escalating– Better case management across partners to reduce

bureaucracy, duplication, riskAdapted from slide by Nick Morris BDCT

The PartnersCommissioners• NHS Airedale, Bradford and Leeds• Emerging Clinical Commissioning Groups• BMDC• NYCC (for Craven)

Providers• Bradford District Care Trust• Bradford Teaching Hospitals• Airedale NHS FT• Bradford Metropolitan Borough Council• Voluntary and Community Sector• North Yorkshire County Council

Integrated functions• Community nursing

• Intermediate care services

• Community therapy services

• Long-term conditions management

• Long-term support and care

• Rehabilitation and reablement

• Associated support services - VCS

• Opportunities to include MH + LD services

The programmeAccess Assessment,

diagnosis + care planning

Community beds

Home-based support Falls and bone health Long-term conditions

Estates IT Performance

Assistive technology VCS Communications

HR + OD Finance Risk stratification

Mental health and dementia

En

able

Scale of Step Up Intermediate Care

Principle: Care close to home

Maximise care at home.Minimise need for hospitalisation.

Dr Tom Downes 2008

Timescale: 2-3 years

• 2011/12 Transfer + achieve consensusTransfer of community services and development of strategy

• 2012/13 ChangeEarly wins: test-sites across District of teams working together, common criteria, assessment and records, enablement working alongside therapy and community nursing

• 2013/14 Polish + make it stick111, pooled budged, single management, health + social care services delivered from community-based hubs

Practices putting in proposals

now

Introducing Mrs Jones…

District

nurse

GP

OT

podiatrist

Out-patient

s

Social worke

r

Social services OT

Physio

Practice nurse

Home care Heart

doc Diabetes doc

Warden

BDCT BMDC InCommunities BTHFT VCSANHSFT GP

Discharge team

Equipment services

CMHT

Housinggrants

MATS

Community Matron

Discussion and questions