Integrating Care for ‘Sally Ford’ and her family – learning from Salford, UK

David Dalton Elaine Inglesby-BurkeChief Executive Executive Nurse Director

“Integrated health and social care for older people has demonstrated the potential to decrease hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning”Curry and Ham, Clinical and Service Integration – The Route to Improved OutcomesKing’s Fund, 2010

High levels of need

National and international evidence

Significant populationgrowth

Significant cost of care

Poor experience of care

Service duplication

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High demand and rising

34,541 people aged 65+, 28% projected increase

1: 14 have dementia and over-represented in acute beds

Growth in limiting long-term illness

Disability-free life expectancy

2,130 falls related A&E attendances

Growth in people living alone: 12,542 in 2011 to 15,998 in 2030

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Salford’s approach

• System shift from reacting to anticipating

• Personalised, shared care planning; ‘Sally’ at the centre

• Tell your story once, have one assessment, one key worker, supported by one integrated system

• Outcomes driven support

Achieving greater

independence and improved wellbeing for

older people in Salford by integrating care within

communities

Create greater independence and

resilience within communities through the

increased use of local assets

Help older people and their carers navigate services and support

themselves through the use of new technologies and the creation of an

integrated care hub

Deliver a structured approach to population health & wellbeing, with

targeted support to those most at risk and their

carers, through multidisciplinary working

• Map existing assets within both neighbourhoods• Engage older people to identify those assets that are

most valued• Increase access to local community groups• Expand befriending and volunteer support• Develop inter-generational support through working

with local schools• Increase prevention and early intervention

• Implement solutions that support self care• Implement assistive living technologies• Develop an information portal and directory of services /

support• Rationalise the number of points of contact for older

people• Provide structured support post discharge from hospital• Develop care navigator role

• Risk stratification to identify people at risk of hospitalisation or admission to care homes

• Fortnightly multi-disciplinary reviews• Health screening• Develop shared care protocols and shared care plans• Timely management for individuals in a crisis• Establish mechanisms to share information between

care providers / professionals• Education and support for individuals and their carers• Increased access to community-based care and support• Increase prevention and early intervention

Primary Drivers Secondary Drivers

• Breakthrough Series Collaborative• 7 multi-agency Project Groups• 130 people actively involved

– Health and social care staff, older people, care homes, voluntary and charitable organisations

• Broader stakeholder engagement• Ongoing co-design and testing

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Neighbourhood collaborative

Integrating care for Sally Ford

Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support

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Local community assets enable older people to remain independent, with greater confidence to manage their own care

1

Centre of Contactacts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring

2

1

Promoting independence for older people Better health and social

care outcomes Improved experience for

services users and carers Reduced health and

social care costs32

Local Community Assets

Befriending1 Carer Support

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Self Care7

Community Groups5

Telecare6

Way to Wellbeing3

Volunteers8

Local Employers9

Housing & Transport4

Local venues10

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Centre of Contact (single point of access)

Post Discharge Support

Navigation

Remote Telecare

Monitoring

Health coaching

Self Care support

Proactive follow up for people following their discharge from hospital, include a phone call within 48 hours of discharge. People at ‘high risk’ of readmission would followed up for up to 30 days or more.

Guiding people to the appropriate part of the health and social care system to get the support they need, linking to a directory of services to support people in accessing local community assets.

Helping people to gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified goals.

Providing people with information about their conditions, promoting healthy behaviours and helping with the emotional impact of chronic illness. People could be followed up over the phone for a specific period to encourage them to be more active participants in their care

Integrating existing care monitoring systems (e.g. community alarms) and new telehealth solutions, acting as central monitoring hub.

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Risk stratification2

2

Shared care protocols3

Shared care protocols are agreed between all members of the MDG, including End of Life care, multimorbidity and dementia care.

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Hospital specialist

Practice nurse

Socialworker

DistrictnurseGP

Mental Health

Care and support5

Individuals receive care and support from a range of agencies, supported by integrated IT and shared care records. Individuals, their families and carers are supported to play an active role in their own care.

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Performance review7

The MDG meets regularly to review its performance and decide how it can improve its ways of working. Review of pooled or virtual budget.

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Case conference6

A small number of individuals with the most complex needs will be discussed at a multi-disciplinary case conference, to help plan and coordinate their care. Individuals are assigned a key worker to support their needs.

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Population registry1

Each MDG holds a register of all people who are aged 65 or over. The register is based on the ‘list’ of the federated GP Practices that are members of the MDG.

1

An integrated care plan is agreed with each individual. The content varies according to risk and need, but includes a focus on primary and secondary prevention. All individuals are re-assessed though the frequency is determined by their level of risk.

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Care planning4

The MDG stratify the register by risk of hospital emergency admission (and readmission) and admission to care homes. Screening tools are used to identify risk factors.

Community assets

Community services

Neighbourhood MDGs

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Wellbeing Plan

Care Plan

Independence Plan

SupportedIndependence

Plan

SHARED CARE PLANS STANDARDS

Care Home

standards

Home care and intermediate

care standards

GP standards

Carer support and disease

management

Able Sally 71%: c. 24,850

Needs Some Help 17%: c.6,000

Needs More Help 9%: c.3100

Needs A Lot Of Help 3%: c.1050

Sally’s standards

Segmentation, care plans and standards

2020 improvement measuresEmergency admissions and readmissions

• 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn) • Reduce readmissions from baseline • Cash-ability will be effected by a variety of factors

Permanent admissions to residential and nursing care• 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn) • Savings directly cashable but need to be offset by cost of alternative care (especially

increased domiciliary care)

Quality of Life, Managing own Condition, Satisfaction• Maintain or improve position in upper quartile for global measures• Use of a variety of individual reported outcome measures

Flu vaccine uptake for Older People• Increase flu uptake rate to 85% (from baseline of 77.2%)

Proportion of Older People that are able to die at home• Increase to 50% (from baseline of 41%)

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What will be different for Sally Ford and her family?

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• Greater independence Able to live at home longer

• Reduced isolation Increased opportunities to participate in community groups and local activities

• Confidence in managing own condition and care

Sign-off own care plan and agree who it should be shared with

Support to monitor own health

• Know who to contact when necessary

One main telephone contact number for advice and support

• Increased community support, specialist care when necessary

Access to a named individual to coordinate care and support

• Support to plan for later stages in life

Agreed plan for last year in life

Financial and contractual levers

• £100 million pooled budget• Four year investment and dis-investment plan

- Commitment to reduce acute beds, based on cost not price reduction- Transparency and open book accounting

• Alliance Agreement- Collaborative arrangement without need for new organisational forms- Aligns interests of commissioners and providers- Collective ownership of ‘gain’ or ‘pain’

• Potential to evolve into a Lead Provider model• Exploring alternative payment mechanisms,

including capitation14

Critical success factors

• Shared vision: ‘Sally Ford’ • Measureable, joint outcomes• Improvement method / testing• Client involvement in redesign• Use of data / integrated records• Structure and pace of implementation • Joint governance and management arrangements• Financial risk and benefit sharing

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WORK IN PROGRESS - DRAFT 14/11/13 16

Table Exercise

Reflect on learning from the four presentations – Key takeaways

10 minutes

Report out – 10 minutes

Wrap up and Thank you!!