Salford’s Integrated Care Programme
“Developing an integrated care community- Delivering in
Partnership”
Melanie Walters
Making Integration Work
10th December 2014
Statutory partners
Salix Health
• Integrated care programme initiated in late 2011,
formalised in May 2012
• Population of circa 230k, of which 35k aged 65+
• Area of significant deprivation and health inequalities
• Largely co-terminus geography: CCG, City Council,
Salford Royal and Greater Manchester West
• History of whole-system redesign and successful
partnership working
3
Background
Salford’s Integrated Care Programme
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
3
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 costs
32
WORK IN PROGRESS - DRAFT 14/11/13 5
Governance and programme structure
2020 targets – what and why?Emergency 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%)
Additional local measure selected for BCFDiagnosis of Dementia against estimated prevalence rates - BCF 7
‘design principles’
What Issues
Population size Core integrated team to cover c.30,000 to 50,000 (all age) population, with some specialist services at higher level – cluster of teams
Critical mass to support sufficient range of services and staff Reflect future demand
Team –configuration and location
Include health and social care staffOften, but not necessarily based on GP practices and supported by co-location
Can have shared managementand pooled budgetsRole and scope of ‘care coordinators’
Geography Best based on natural communities and patient flows
Recognise may not ‘fit’ with organisational boundaries
Information and Technology
Integrated records, decision support, patient monitoring and risk stratification (categorising people into groups according to need / risk)
Both to coordinate care and provide it
Spectrum of needs Avoid excessive focus on highest acuity (hospitalisation) – balance with earlier intervention and prevention
E.g. represented by pyramid of need, Salford ‘just enough care’ model
Spectrum of services
Ensure include full range of health and social care, as well as Third sector and wider support
Initially share knowledge of what is already available
Engage and empower people
For older people to have greater controlAnd for staff to further integrate services
E.g. deciding what services and whenE.g. integrate supporting systems
Keep it Simple in Salford
Make the system understandable for people,customers and patients.
Priority to reduce hand-offs between elements in the system
8
Salford’s Integrated Care Programme
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
3
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 costs
32
10
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
11
Sally friendly schools
Sally volunteers
Sally Friendly City
Sally friendly supermarkets & businesses
Befriending services
Sally’s StandardsTech and tea
Housing
Transport
Builds on dementia friendly city and maps across to the Social Value Charter
Wellbeing plans
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. This could include a phone call within 48 hours of discharge. People at ‘high risk’ of readmission (stage 2 in MDG) would be followed up for 30 days or more.
Guiding people to the appropriate part of the health and social care system to get the support they need. This function could link 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
This could integrate existing care monitoring systems (e.g. community alarms) and new telehealth solutions, acting as central monitoring hub.
Level 1 - Care Navigator, Directory of Services, PLANS, W2W Portal
Level 2 – Care Navigator Sign Posting and Structured Assessment, Rehabilitation, Reablement and More Specialist Assessment
Health CoachingIncluding
Diabetes Care Call
Redesigned ASS-CT and
Intermediate Care SEP
MDG Post DischargeGP Referrals Emergency Admission New Diagnosis
INBOUND + OUTBOUND CALLSHEALTH COACHINGNAVIGATIONDISEASE MANAGEMENTTELEHEALTH MONITORING
Ambulance GP Intermediate Care services
Integrated Teams Cardiac Rehab Pulmonary Rehab
Telehealth + Telecare + Equipment
Sally and her family, carers
Specialist Support accessed via the Centre of Contact such as: district nursing, podiatry, occupational therapy, heart failure, COPD, diabetes and other services
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Continuum of Proactive Care Services
All adults
Planned for several
years
CCG funded
Rate per
registered patient
NEEDS SOME HELP/
NEEDS MORE HELP
SALLY
Local Commissioned
Service for LTCs*
All vulnerable
adults**
Planned for 1 year:
subject to national
review
NHSE funded
Rate per
registered patient
NEEDS SOME HELP/
NEEDS MORE HELP
SALLY
Enhanced Service:
Avoiding Admissions
Frail elderly:
approx > 65 yrs
Planned for 4
years
ICP/Better Care
Fund funded
Rate per hour for
MDG meetings
NEEDS MORE HELP/
NEEDS A LOT OF
HELP SALLY
Multidisciplinary
Groups (ICP)
>75 year olds
Permanent unless
contract changes
NHSE funded
Part of core
contract
NEEDS MORE HELP/
NEEDS A LOT OF
HELP SALLY
Accountable GP >75
year olds
Last year of life
Permanent unless
QoF changes
NHSE funded
QoF Payment
NEEDS A LOT OF
HELP SALLY
End of Life Care/GSF
Shared care record
Principles
• System shifts 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
Enablers
• Alliance Agreement
• Pooled fund covering most
health and social care
• Four-year investment and
savings plan (BCF+)
• Workforce development
• Organisational development
• Routine progress review
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Lead Commissioner
P
PP
P PP
Alliance AgreementBENEFITS Full range of services within a single
management arrangement – more effective, efficient and coordinated care
Collaborative environment without the need for new organisational forms
Aligns interests of commissioners and providers, removing organisational and professional ‘silos’ that contribute to fragmented and sub-optimal care
Collective ownership of opportunities and responsibilities; any ‘gain’ or ‘pain’ is linked to performance overall
Supports a focus on outcomes and incentivises better management of population demand
Progressing framework for an integrated care organisation
Commitment to move to all adult population
• CCG, City Council, SRFT, GMW
• Health, social care & wellbeing for 65+ population
• Some services subcontracted
• Includes commissioned 3rd sector services
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Challenges & Critical Success Factors
Challenges
• Implementing change whilst keeping up with today’s work
• Pressures on primary care
• Current model of primary care provision
• Data & information sharing
• Intermediate care- best fit
Success Factors
• Senior leadership
• Governance
• Common vision
• Trust
• Communication
• Function v form
• Carrots and sticks
• Investment in programme management/ operational posts to support the work
Integrated Care -everyone playing their part
Much more than a partnership!