Wessex Academic Health Sciences Network

23 April 2015

Suzanne Wixey, Programme DirectorIntegrated Care and Support

My life a full life is a new way of working together towards building sustainable health and social care on the Island

Collaboration between the Isle of Wight Council, Isle of Wight NHS Trust and the Isle of Wight Clinical Commissioning Group, working in partnership with One Wight Health, third sector, local people, families and carers

Catalyst for change, bringing together organisations to deliver a significant programme of change

The focus is on person centred community responses to ensure people receive co-ordinated care and support

Benefits Less admissions to hospital Reduction in bureaucratic

systems Greater co-ordination of

care and support across the organisation and within communities

Benefits Improved outcomes Greater freedom and choice Empowered people

Benefits Reduction in referrals Greater co-ordination

ensuring right agency responds

Reduction in admissions to long term care

Benefits GP’s time freed up Support closer to

practices Greater co-ordination

Trust

PublicIWC

CCGs

Anticipated Benefits

What we have delivered• Developed a vision, with local people for the delivery of integrated care and

support which works well with people families and carers

• Focussed on prevention rather than cure, with health and social care focussing on maintaining wellbeing in communities – before people need services

• Enhanced multi-agency planning and organisational collaboration across the statutory, voluntary and private sector

• Improved access to local information and advice enabling people to make informed choices about what support is available in local communities

• Made the most of local resources ensuring the development of the health and social care system is sustainable in the longer term, pooling budgets, creating integrated services, working in partnership with the voluntary sector and local communities

What we have delivered• Promoted self care and self management to the Island population

• Secured 5.6m to eradicate social isolation for older people

• Delivered a crisis response service for people on the Island, reducing inappropriate demand on hospital and residential placements

• Developed integrated approaches on a locality basis, ensuring care and support is delivered closer to home – working with GP’s primary care and multi agency teams

• Developed an evaluation framework and integrated metrics approach to inform future commissioning and development with a firm evidence base

Proposed MLAFL Evaluation Metrics • Emergency readmissions within 30 days of discharge from hospital (PHOF 4.11)• Hip fractures (65-79 and 80+) (PHOF 4.14)• Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s* (NHSOF 2.3.ii• Estimated diagnosis rate for people with dementia (PHOF 4.16, NHSOF 2.6i) • Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital

into rehabilitation/reablement services (ASCOF 2B, NHSOF 3.6i) (There has been a small change to the definition of the measure, but 2011/12 data are broadly comparable with 2010/11 data)

• Proportion of older people (65 and over) who were offered rehabilitation following discharge from acute or community hospital (NHSOF 3.6ii)

• Proportion of people who use services who have control over their daily life, to be revised from 2014 (ASCOF 1B). (Caution should be exercised when comparing the underlying 2011/12 data to 2010/11 data due to changes in survey methodology).

• Proportion of adults in contact with secondary mental health services living independently, with or without support (PHOF 1.6, ASCOF 1H) (2011/12 data are not comparable with 2010/11 data, as 2011/12 data is based on the last quarter of the year).

• Permanent admissions to residential; and nursing care homes, per 1,000 population (ASCOF 2A). (2011/12 data are not comparable with 2010/11 data)

• Delayed transfers of care from hospital, and those which are attributable to adult social care (ASCOF 2C). (A move from weekly to monthly data means that 2011/12 data are not comparable with 2010/11 data).

• Overall satisfaction of people who use services with their care and support (ASCOF 3A) (Caution should be exercised when comparing 2011/12 data to 2010/11 data due to changes in survey methodology).

• Proportion of carers who report that they have been included or consulted in discussion about the person they care for (ASCOF 3C) (Carers Survey biennial – no carers data for 2011/12).

Inform Workstreams towards “I” and “We”

statements

Health and Wellbeing Board

MLAFL Programme Board

MLAFL Evidence Base

External research and dataCrisis ResponseSelf Care/Self

ManagementIntegrated

Locality Teams

Voluntary Sector prospectus

funded projects

University of Southampton – protocol for PLANS and Social Networking study on the Isle of Wight Research Co-ordinator – focus groups, one-to-one interviews opened and closed, questionnaires and other innovative and participatory tools with staff, people, families and carers National data/evidence statistics – HES, GP National Patient Survey, Reports/Journals Local data/evidence – Healthwatch, People Matter MLAFL Evaluation Metrics – ASCOF, PHOF, NHSOF

Staff self-evaluation journal Programme theory Monitoring data to track project change in relation to KPIs/CSFs (“I” and “We” statements) Plurality methodology Cost-benefit analysis

Help and Care Health Failure Support Group Age UK Digital Inclusion Age UK Care Navigators Footprint Trust Warmer Wight Plus

Proposed Integrated evidence-base model

Vanguard

• In March 2015 the Isle of Wight was chosen as a national Vanguard site

• One of 29 shortlisted from 269 who put forward their ideas for how we want to redesign care and support

• Maximise the use of resources and avoid duplication and provide better solutions to outdated provision

VanguardWhat we want to achieve?

• Develop local community leadership within new and existing services that integrate and co-ordinate sustainable development opportunities and outcomes

• Develop leadership and workforce competencies to deliver truly integrated care• Continue to build community capacity with public health and other key

stakeholders• Embrace innovation that enhances the lives of individuals on the Island• Nurture community strengths and adopt an asset based approaches to health

and wellbeing, care and support• Improve the quality and effectiveness of support and services which will have a

real impact on people and communities• Develop the next generation community- based models of health and well being

and enhance the lives of individuals, families and carers on the Island• Use our newly acquired Vanguard status to lead on the development of

innovative game changing models

All Services for Health and Social Care to be triaged through Single Point of Contact, which includes all Organisations

· 999

· 111

· Rehabilitation & Reablement

· Crisis Response

· Hospital Telephony

· Community Nursing

· Wightcare Community Alarm Service

· Out of Hours

· Voluntary Sector

· Patient Transport

· Hospital Car Service

· Adult First Response

· Pharmacy

· Social Workers

· Telehealth

Proactively targeting population using a Risk Stratification programme

Innovative Commissioning new models of care to achieve quality

Expanding Leadership roles in primary care to include a wide range of professionals e.g. Health and Social Care, pharmacist, voluntary sector etc.

Moving towards Multispecialty Community Providers for a wider range of care for individuals

Making fuller use of digital technology new skills and roles.

Promoting Self-care and Self-Management at every opportunity to reduce demand linking into the Voluntary Sector

7 day working developing expert generalist to work a lot more intensively with individuals and more accessible urgent care services

Development of Estate to deliver community Integrated Health and Wellbeing centres

Developing sustainability of Primary and Secondary Care across Health and Wellbeing system as a whole.

Extended group practices to form either as federations, networks or single organisations

Build on the development of working together across Primary and Secondary Care to ensure seamless transition of care and support. Achieving full traction of key priorities across Primary and Secondary Care, for example:

· Speeding up flow through hospital· Reduced inappropriate Non-elective

Admissions· Reduced Re-admissions· Reducing Admissions to Nursing /

Residential Homes

Flexibility in working with Primary Care i.e. Digital Consultation with Health and Care Professionals (Consultants, Nurses, AHP, in reaching into Nursing and Residential Homes)

Using local intelligence to target specific populations to provide better outcomes i.e. quality of Health and Care for people, impact on individual Health and Wellbeing and System efficiencies

Building resilience with the third sector (Nursing Residential Homes, Voluntary Sector)

Recruit through partnership Acute specialist care to outreach into Community

Integrated Single point of access Primary Care Lead Localities Fully Integrated Acute providerPrevention and Early Intervention

Creating sustainable change across the system as a whole, where it makes sense and if needed.

· Activated Patients

· Helping people to live longer and more healthy lives

· Focusing on early intervention and prevention.

· Healthy workplaces

· Research and Evaluation to measure effectiveness and impact to contribute to redesign of services and continually meet local need.

· Develop our own capacity and capability

· My Life Get Active

· Empower and involve Communities

· Raising awareness of Health screening programmes available and encouraging participation

Key Enablers

CommissioningContracts capitated

Finance Information Technology

Integrated Performance Metrics

Workforce Governance

IW Council IW NHS Trust IW CCG Voluntary Sector Primary Care Nursing & Residential Homes IW Prisons IW Providers

Cost Benefits QualityDeveloping a Community currency through a pathway costs

Added Value to improve outcomes and quality for individuals, whilst delivering cost efficiencies

Integrated Model of Care

New Models of Care

Vanguard

• Working with KPMG creating a roadmap for the Isle of Wight - MLAFL powered by Vanguard Programme

• Visit by New Models of Care Team 18/19th May• Building a compelling story of the journey so far, where we

can accelerate progress and what help we need• Learning from other sites• Peer visits to other sites• Excited and enthused about the future and the opportunity

Vanguard will bring to the Island• Aspiring to be a national leader for integrated care

Delivering the FutureA shared vision for health and social care on the Island

Contact details

Suzanne WixeyProgramme Director Integrated Care and SupportRoom K, Innovation CentreSt. Cross Business ParkNewportIsle of WightPO30 5BW

Email: suzanne.wixey@iow.nhs.ukTel: 01983 822099 x 3045

Email: MLAFL@iow.gov.ukWeb: www.mylifeafulllife.com