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Health and Care Innovation Expo 2014, Pop-up University S79 - Day 1 - 1545 - Building the house of care Dr Martin McShane Jacquie White #Expo14NHS
Citation preview
Building the House of Care
January 2014
Martin McShane
Jacquie White
Ed Mitchell
Overview
bull Context
bull Principles
bull Resources
bull Discussion
2
bull Context
bull Principles
bull Resources
bull Discussion
3
0
10
20
30
40
50
60
70
80
90
100
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Pat
ien
ts (
)
Age band (Years)
Morbidity (number of ETGs) by age band
0
1
2
3
4
5
6
7+
Number ofconditions
BMJ 2009339b2803 4
A man being treated for heart failure in UK primary care rejected the offer to attend a specialist heart failure clinic to optimise management of his condition He stated that in the previous two years he had made 54 visits to specialist clinics for consultant appointments diagnostic tests and treatment The equivalent of one full day every two weeks was devoted to this work
Changing the nature of the conversation
hellipthe biggest challenge
5
The soft stuffhellipis the hard stuff
6
Mindsets
and beliefs
Values
Individual
behaviours
SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming
your organisationrsquo 2010
Needs
(met or unmet)
Year of Care Costs
7
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Overview
bull Context
bull Principles
bull Resources
bull Discussion
2
bull Context
bull Principles
bull Resources
bull Discussion
3
0
10
20
30
40
50
60
70
80
90
100
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Pat
ien
ts (
)
Age band (Years)
Morbidity (number of ETGs) by age band
0
1
2
3
4
5
6
7+
Number ofconditions
BMJ 2009339b2803 4
A man being treated for heart failure in UK primary care rejected the offer to attend a specialist heart failure clinic to optimise management of his condition He stated that in the previous two years he had made 54 visits to specialist clinics for consultant appointments diagnostic tests and treatment The equivalent of one full day every two weeks was devoted to this work
Changing the nature of the conversation
hellipthe biggest challenge
5
The soft stuffhellipis the hard stuff
6
Mindsets
and beliefs
Values
Individual
behaviours
SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming
your organisationrsquo 2010
Needs
(met or unmet)
Year of Care Costs
7
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
bull Context
bull Principles
bull Resources
bull Discussion
3
0
10
20
30
40
50
60
70
80
90
100
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Pat
ien
ts (
)
Age band (Years)
Morbidity (number of ETGs) by age band
0
1
2
3
4
5
6
7+
Number ofconditions
BMJ 2009339b2803 4
A man being treated for heart failure in UK primary care rejected the offer to attend a specialist heart failure clinic to optimise management of his condition He stated that in the previous two years he had made 54 visits to specialist clinics for consultant appointments diagnostic tests and treatment The equivalent of one full day every two weeks was devoted to this work
Changing the nature of the conversation
hellipthe biggest challenge
5
The soft stuffhellipis the hard stuff
6
Mindsets
and beliefs
Values
Individual
behaviours
SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming
your organisationrsquo 2010
Needs
(met or unmet)
Year of Care Costs
7
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
BMJ 2009339b2803 4
A man being treated for heart failure in UK primary care rejected the offer to attend a specialist heart failure clinic to optimise management of his condition He stated that in the previous two years he had made 54 visits to specialist clinics for consultant appointments diagnostic tests and treatment The equivalent of one full day every two weeks was devoted to this work
Changing the nature of the conversation
hellipthe biggest challenge
5
The soft stuffhellipis the hard stuff
6
Mindsets
and beliefs
Values
Individual
behaviours
SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming
your organisationrsquo 2010
Needs
(met or unmet)
Year of Care Costs
7
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Changing the nature of the conversation
hellipthe biggest challenge
5
The soft stuffhellipis the hard stuff
6
Mindsets
and beliefs
Values
Individual
behaviours
SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming
your organisationrsquo 2010
Needs
(met or unmet)
Year of Care Costs
7
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
The soft stuffhellipis the hard stuff
6
Mindsets
and beliefs
Values
Individual
behaviours
SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming
your organisationrsquo 2010
Needs
(met or unmet)
Year of Care Costs
7
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Year of Care Costs
7
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Relationship between number
of long-term conditions and cost
8
LTC Year of Care Programme
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Gearing of investment across the system
Public Health
Social Care
(HampWB Board)
Primary Care pound200
CommMH pound500
Specialised pound300
Acute pound1000
pound2000head of population
NHS England CCGs
9
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
NHS Expo Seminar Domain 2
Gearing in activity into acute care
10
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
11
GP Specialist
1990
Specialist
2014
CARE GAP A
c
t
i
v
i
t
y
Complexity
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Qu
ality
of
life
pound1 pound10 pound100 pound1000
ICU
ACUTE CARE
0
COMMUNITY CARE
Self-management
Long Term Condition
Management incl Cancer
Third sector
provision
Primary Care
100
Consultant-led
services
Specialist teams Specialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
pound5000
Cost of Care per Day
Risk profiling
12
COMPLEX CARE PRACTICE
Bridging the gap
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
LTC Year of Care Programme
Impact of coordinated care
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Person centred
coordinated care
ldquoMy care is planned with people who
work together to understand me and my
carer(s) put me in control co-ordinate
and deliver services to achieve my best outcomesrdquo
Communication
Information
Decision-making Care planning
Transitions
My
goalsoutcomes
Emergencies
14
What people with LTCs want
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
1 Engaged informed empowered individuals and carers
2 Organisational and clinical processes
3 Health and care professionals working in partnership
4 Commissioning
15
Person Centred Coordinated Care
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Engaged
informed
individuals amp
carers
Commissioning
Organisational
amp clinical processes
Person-
centred
coordinated
care
Health amp care
professionals
committed to
partnership
working
Plan
Study
Do
Act
The House of Care
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
ndashInformational continuity
ndashManagement continuity
ndashRelational continuity
17
The House supports
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
The House of Care in value to peoplepatients
The House supports National Voices lsquoIrsquo statements
My goalsoutcomes eg bull All my needs as a person were
assessed and taken into account
Communication eg bull I always knew who was the
main person in charge of my care
Information eg bull I could see my health and
care records at any time to check what was going on
Decision-making eg bull I was as involved in
discussions and decisions about my care and treatment as I wanted to be Care planning eg
bull I had regular reviews of my care and treatment and of my care plan
Transitions eg bull When I went to a new
service they knew who I was and about my own views preferences and circumstances
Emergencies eg bull I had systems in place so
that I could get help at an early stage to avoid a crisis
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
The House of Care in value to NHS
pound12bn Avoid ambulatory care
sensitive admissions
though eg following
NICE guidelines (1)
pound08bn Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty comorbid (2)
pound08-12bn Reduce use of low value drugs
devices and elective procedures
using commissioning analytics and clinician education (3)
pound02-04bn Empower people in
supportive self-
management (4)
pound1-16bn Shift activity to cost
effective settings
eg pharmacy minor
ailments (5)
cpound55bn Incentivised wellness
programmes in healthy
pop amp early stage LTCs inc
smoking cessation salt darr
exercise uarr(6)
pound04-06bn Avoidance of drug errors
eg through electronic
recordse-prescribing (7)
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
20
Community Care
Primary Care
GenHospitalseral
University Specialist Facilities
Social Care
General Hospital
ICare
The Future 2014-2019
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
The House of Care - Person centred coordinated care at three levels National What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels
Local How local health
economies ensure that the
House of Care involves a
whole system approach
including lsquomore than
medicinersquo offers
Personal How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
CCGs Building the House at the local community level
What
bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements
bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)
Which
bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)
Where when whom
bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom
How
bull Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs contracts incentives etc that match the model of care)
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Building the House ndash
The House of Care Toolkit
bull A framework to bring together all the relevant national guidance published
evidence local case studies and information for patients and their carers
bull It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned
bull Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved based on current evidence
and details about where to find additional information
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
To Enter the House first chose your level
National Personal Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level
Supporting for
professionals services
users and carers to work
together to understand plan
and deliver person centred
coordinated care
National and international
guidance evidence tools
and resources that will
enable the construction of
the House of Care at the
next two levels
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Organisational and Clinical Processes
Person centred-
coordinated care
Health and Care
Professionals
committed to
partnership
working
bull Integration
bull Culture
bull Technology
bull Care Co-ordination bull Care Planning
bull Information and Technology
bull Care Planning
bull Safety and Experience
Informed and
engaged patients
and carers
bull Self Management
bull Information and
Technology
bull Group and Peer
Support
bull Care Planning bull Carers
Commissioning bull Service User and Public Involvement
bull Contracting and Procurement
bull Needs Assessment and Planning
bull Joint commissioning
bull Metrics
bull Evaluation
bull Care Planning
Build my own
house
Click on the links below for
more information about each
component and use this to
build your own house
bull Guidelines Evidence and
National Audits
bull Workforce and Organisational
Structures
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Enables individuals to make informed decisions which are right for them and empower them to self-care for their long term conditions in partnership with health and care professionals It relies on four key components all of which must be present for the goal person-centred coordinated care to be realised
ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one
ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them
ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible
ndash Health and care professionals working in partnership ndash listening supporting and collaborating for continuity of care
26
Person centred-
coordinated care
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Care Planning Professionals working in partnership with people living with long term conditions and
their carers identifying priorities discussing care and support options agreeing
goals they can achieve themselves and co-producing a single care plan that meets
their physical social and emotional wellbeing needs regardless of how many
long-term conditions they have
Consultation
preparation
Research by the Health
Foundation has identified
elements that can make a
consultation between
patient and healthcare
professional more
successful
Key Components
bull Focussing on
receptionists
conversations in general
practice
bull Practice Health
Champions
bull Appointment guides
Back to house
Care planning process
An ongoing process
encouraging an interactive
partnership between clinician
and patient to support self
management of patients and
their long term condition
Key Components
bull Information provided to
the patient prior to the
appointment
bull During the appointment
achievable goals should
are set in partnership I
bull Capturing gaps between
preferences and care
received
bull Feeding back preferences
to inform future planning
Medicines
optimisation
To ensure the best possible
outcomes from medicines
for people living with long
term conditions
Key Components
bull Ongoing open dialogue
with the patient andor
their carer about their
choice and experience of
using medicines to
manage their condition
bull Recognising the patientrsquos
experience may change
over time even if the
medicines do not
Engaged
informed
individuals
and carers
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Engaged
informed
individuals
and carers
Consultation Preparation
Resources
Right Conversation at the Right Time The Health Foundation
httpwwwrightconversationorg
When doctors and patients talk making sense of the consultation The Health
Foundation
httpwwwrightconversationorgwhendoctorsandpatientstalkpdf
Back to care
planning
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Engaged
informed
individuals
and carers
Care Planning Process
Resources
Shared decision making NHS England
httpwwwenglandnhsukourworkpesdm
Tools for shared decision making NHS England
httpwwwenglandnhsukourworkpesdmtools-sdm
Care Planning Royal College of General Practitioners
httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx
Deciding together Care planning in long term conditions NHS Kidney Care
February 2013
httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care
20planning20in20long20term20conditions[1]pdf
Back to care
planning
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Engaged
informed
individuals
and carers
Medicines Optimisation
Resources
Medicines Optimisation Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England Royal
Pharmaceutical Society
httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-
most-of-their-medicinespdf
Good practice in prescribing and managing medicines and devices General
Medical Council
httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf
Back to care
planning
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Integration Ensuring care is designed and delivered around the needs of the individual
Integration is particularly important for people with complex care needs
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support enabling them to live not just longer but
better lives
Care is planned with people who work together to understand me and my
carer(s) put me in control co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers
Key Components
bull Single point of contact
bull Professionals talk to each other
bull Services quick and responsive
people are promoted to stay
independent and active
bull Care developed around the
individual and not the system
Care Transition
Ensuring a seamless transition for
people with long term conditions
between different care settings
Key Components
bull Transition following discharge from
hospital
bull Transition related to changes in long
term care needs
bull Transition from childrens to adult
services
Health amp care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Interdisciplinary Working
Resources
Integrated care for patients and populations Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum The Kings Fund
httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-
improving-outcomes-working-together
Integrated Care and Support Pioneers programme NHS IQ
httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-
careaspx
Integrated Care ndash Better Care Fund ndash Local Government Association
httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-
journal_content56101804096799ARTICLE
Integrated care value case toolkit
httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-
journal_content56101804060433ARTICLE
ICASE - Integrated Care Support and Exchange
httpwwwicaseorgukpgdashboard
Kings Fund Integrated care making it happen
httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen
Back to integration
Health amp care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
Care Transition
Resources
Lost in transition Moving young people between child and adult health
services Royal College of Nursing
httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf
Transitions between childrenrsquos and adultrsquos health services and the role of
voluntary and community childrenrsquos sector VSS POLICY BREIFING
httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing
Transition National Council for Palliative Care
httpwwwncpcorguktransitions
Coordinated transition between health and social care NICE
httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare
DraftScopepdf
Back to integration
Health amp care
professionals
committed to
partnership
working
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house
The House of Care ndash Build your own house What elements need to be in place for YOUR local population
Commissioning
Organisational and clinical processes
Engaged informed individuals amp carers
Health amp care professionals committed to
partnership working
Back to house