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Integration in Action Workshop
Welcome – Angiolina Foster CBEDirector, Health and Social Care Integration Scottish Government
Integration: yes really!Experience from Fife: Intermediate Care
Fiona MackenzieFife Partnership
Kirkcaldy and Levenmouth CHP
What were we doing?
• Taking a wide range of services across the partnership that had been started over the years, and use them to reshape services in a fully integrated model.
• We call this ICASS – Integrated Community Assessment and Support Service.
• Started in 2009… still work in progress.• Overall aim to provide care at home wherever possible, in an
easily accessible and fully integrated service model.
Integration – The RealityRequired What we have
Increasing activity Resources remain the same or reduced
Easy to access Multiple access points
Integrated design to suit personal outcomes and needs
Separate systems designed to deliver individual organisations aims
Able to respond quickly 5 day service, set up to suit providers
Able to plan an anticipate needs of the most frail
Reactive design with limited structured ACP/Care Manager roles
Designed by users Designed by Services
Pt at Home
Mixing BowlPrevention of Admission
Supporting App Early D/C
IRT
EHCT
CRU
HC
Com Hospital
Com Pharmacy
Sport & Leisure
Carers Trust
Day CareVol Org
Carers
CPN’s
PhysioInt Housing
GP
CRTCAST
DN
SW
COT
Transport
Falls Response
PT
Care Needs Identified
COMMUNITYHOSPITAL
CrisisAnticipatoryNo SPOA
KIRKCALDY & LEVENMOUTH – CURRENT MODEL IC 2009
Just when you have a plan..
• New services come on board - Change Fund .• Intermediate Care comes of age.• Increasingly clear that current model not sustainable = everyone has a
view especially about the role of others.• Partners are responding to issues in own area e.g budget and
emergency access pressures, Council contact centre• Other initiatives get to implementation point, and need to be joined
up coherently.
H@H
Case Management
Assessment, Triage, Inreach to Acute Care, Managing Delays
Home Care, Dementia and Frailty, Community
Rehabilitation
Case Management
35
Integrated Care
Case Management
15
Access PointAdministration
50
20
main actions
• Model how we need to work – relationships always the priority• Leadership group established = one voice.• Access – review and recalculate how teams were working and where
skill mix was needed to reduce admin and duplication of effort for staff
• “Reach in” to acute care to improve decisions and hospital flow• Bring old teams together in new design = pain ++• Ignore boundaries wherever possible
• Simplify language for those outside the system, its difficult enough on the inside.
• Acknowledge future aims e.g have one access point for ICASS and home care.
• Coordinate/ manage the care around the person – explicit role of case manager built in.
• Embed and join up the new roles for people (and there carers) with Dementia and Frailty. Based on 8 pillar model - at last, systematic ACPs as integral part of ICASS.
the good stuff..
• Staff want to improve outcomes – it is what motivates them• When the vision is agreed and others start to see how it fits• Collocation of key staff gave immediate results despite the trauma of
the move.• Use of White Boards and systematic processes eg regular board
rounds involving all of team inc Home care. • Easier to get the right care for the situation using local knowledge and
shared responsibility• If we say everyone matters – we need to act like it.
… and the tricky stuff• Systematic evaluation of complex and cultural change• When things come in left field e.g review of home care ( again),
Hospital at Home introduction.• Data either difficult to collect or not currently available to support
changes – IT systems unable to deliver at present.• Different T&C’s and line management accountabilities. Can be
overcome but not in some critical areas eg. medicines in the community.
• Still essentially 2 + systems involved in developing and delivering integrated model on the ground.
• Would really like to do that but….
and so….
• Hold the Vision• Don’t be fooled into thinking there is a road map for this• Sharpen your compass reading skills• Always design intentionally• Get leaders together and build the relationships • Adapt to whatever comes along – but stick to the vision• “Involve” like your life depends on it – with every stakeholder• Get the data right
Please discuss the presentation you have heard and agree on:
1. The single biggest lesson you have learned?
2. One “Do”?
3. One “Don’t”?
Improving Outcomes Through Integrated Working
Older Peoples Services
NHS Forth Valley & Stirling Council
The Improvement Agenda
Aim - Shift balance of care - Support more people to remain at home or return home - Reduce admission to hospital and improve delays to
discharge - Avoid premature admission to care homes
Embarked on whole system approach• Reablement • Rehabilitation at Home• Short Stay Assessment Beds
Outcomes Comparison
2009 2013
Care at home service users
1285 1403
Older people in care homes
670 472
Balance of Care 18% 35%
Cost of care (care at home)
£6.7m £6.7m
Cost of care (Care Homes)
£9.6m £7.3m
Integrated StructureAchievements and Wicked Issues
• Staffing and Culture• Location/Assets• Procedures• Service user contracts and financial impacts• Evidencing impact for individuals
Moving ForwardStirling Care Village
A Health and Social Care Partnership
Residential (34)
Mental HealthRespite
Palliative
Health Beds (32)
Intermediate Care / Rehab / respite (64)
Comm Team Base
Public and Day services“street”
Please discuss the presentation you have heard and agree on:
1. The single biggest lesson you have learned?
2. One “Do”?
3. One “Don’t”?
Integration in Action
NHS Highland
Jan Baird Director of Adult Care
NHS Scotland Event 2013 -
Collaborating for Quality
Boldly Go……….
Lead Agenc
y Model5
YearPlan
1 April2012
Programme Management
Approach Partnership
Working
Professional Leadership
(Practice Governance Framework)
Governance
Case for
Change
Public Communication
Staff Transf
er
WWW
EBI ………. Evidence
/Evaluation – attribution/ contribution challenges
ManagerialReorganisati
on
IT – access not
integrated systemsEvidence
Base
Quantum
EXAMPLES OF HOW THIS IS MAKING A
DIFFERENCE
EXAMPLES OF IMPACT SO FAR
THE
LONG
AND
WINDING
ROAD
BELFORD HOSPITAL
INVERNEVIS
CARE HOME
Please discuss the presentation you have heard and agree on:
1. The single biggest lesson you have learned?
2. One “Do”?
3. One “Don’t”?
