South Reading Patient Voice

Fiona Slevin-BrownReading Locality Director - Berkshire Healthcare Foundation Trust 25th April 2013

Integrated Care

What our patients want

Knowledge of me and my condition, and my carer as

people

People want their

care co-ordinated

People want care when they

need it

What will our patients say about integrated care?

• I always knew who was the main person in charge of my care.

• I was as involved in discussions and decisions about my care and treatment as I wanted to be.

• I know what is in my care plan. I know what to do if things change or go wrong.

•When I needed support to live at home, services worked together to provide it. I had a say in who would come and provide my care and when.

The case for integration

• The % population over 85 years old is forecast to double. • Many more people with complex health and care needs being cared for in the community.

• We need to deliver improved patient outcomes and community capacity.

• Systems of care need to be changed to provide more care closer to home, enabling people and communities to care for themselves more.

• Need to develop a high quality workforce which is future proof • Limited additional resources locally and nationally• Need to reduce duplication and unnecessary hand-offs currently experienced by our patients

Population and Case load management

Support and care for

patients who are unwell or

recovering

Support and care for

independence

Enhancing the patient experience – to improve health and wellbeing

• An agreed model of integrated care• Development of case co-ordination• Delivery of 24 hour services which further support the system in addressing admission avoidance and timely discharge

• Development of local multi-disciplinary teams including social care, housing and the voluntary sector

• Services which are actively involve people and their carers in the management of their LTC

• A highly skilled competent and confident workforce with defined roles

Features of local integrated care

Integrated

Team

Integrated

Team

Integrated

Team

WIC

Integrated

Team

Specialist Services

Specialist Services

Care Liaison

Community Matron

Practice Nurse

GPDistrict nursing

Social Worker

Rapid Community Access

Specialist Continence Service

Specialist Medical Support

Community Therapists

Specialist Nursing Team

Tissue Viability

FAST

Links with Acute Care, Social Care, SCAS

What will success look like for us?

• Fewer people will require admission into hospital or needing on-going long term care

• Enhanced recovery from episodes of ill health or injury• A more positive experience of care reported by our patients and their carers

• More people will achieve their preferred choice of place of death

• Services which are flexible and responsive, recognising what is important to the patient and carer

• Care is delivered in a way that anticipates our patients needs • Improved recruitment and retention of staff• Improved efficiency and better use of resources