Salford’s Integrated Care Programme

“Developing an integrated care community- Delivering in

Partnership”

Melanie Walters

Making Integration Work

10th December 2014

Statutory partners

Salix Health

• Integrated care programme initiated in late 2011,

formalised in May 2012

• Population of circa 230k, of which 35k aged 65+

• Area of significant deprivation and health inequalities

• Largely co-terminus geography: CCG, City Council,

Salford Royal and Greater Manchester West

• History of whole-system redesign and successful

partnership working

3

Background

Salford’s Integrated Care Programme

Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support

3

Local community assets enable older people to remain independent, with greater confidence to manage their own care

1

Centre of Contactacts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring

2

1

Promoting independence for older people

Better health and social care outcomes

Improved experience for services users and carers

Reduced health and social care costs

32

WORK IN PROGRESS - DRAFT 14/11/13 5

Governance and programme structure

2020 targets – what and why?Emergency admissions and readmissions• 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn) • Reduce readmissions from baseline • Cash-ability will be effected by a variety of factors

Permanent admissions to residential and nursing care• 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn) • Savings directly cashable but need to be offset by cost of alternative care (especially

increased domiciliary care)

Quality of Life, Managing own Condition, Satisfaction• Maintain or improve position in upper quartile for global measures• Use of a variety of individual reported outcome measures

Flu vaccine uptake for Older People• Increase flu uptake rate to 85% (from baseline of 77.2%)

Proportion of Older People that are able to die at home• Increase to 50% (from baseline of 41%)

Additional local measure selected for BCFDiagnosis of Dementia against estimated prevalence rates - BCF 7

‘design principles’

What Issues

Population size Core integrated team to cover c.30,000 to 50,000 (all age) population, with some specialist services at higher level – cluster of teams

Critical mass to support sufficient range of services and staff Reflect future demand

Team –configuration and location

Include health and social care staffOften, but not necessarily based on GP practices and supported by co-location

Can have shared managementand pooled budgetsRole and scope of ‘care coordinators’

Geography Best based on natural communities and patient flows

Recognise may not ‘fit’ with organisational boundaries

Information and Technology

Integrated records, decision support, patient monitoring and risk stratification (categorising people into groups according to need / risk)

Both to coordinate care and provide it

Spectrum of needs Avoid excessive focus on highest acuity (hospitalisation) – balance with earlier intervention and prevention

E.g. represented by pyramid of need, Salford ‘just enough care’ model

Spectrum of services

Ensure include full range of health and social care, as well as Third sector and wider support

Initially share knowledge of what is already available

Engage and empower people

For older people to have greater controlAnd for staff to further integrate services

E.g. deciding what services and whenE.g. integrate supporting systems

Keep it Simple in Salford

Make the system understandable for people,customers and patients.

Priority to reduce hand-offs between elements in the system

8

Salford’s Integrated Care Programme

Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support

3

Local community assets enable older people to remain independent, with greater confidence to manage their own care

1

Centre of Contactacts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring

2

1

Promoting independence for older people

Better health and social care outcomes

Improved experience for services users and carers

Reduced health and social care costs

32

10

Wellbeing Plan

Care Plan

Independence Plan

SupportedIndependence

Plan

SHARED CARE PLANS STANDARDS

Care Home

standards

Home care and intermediate

care standards

GP standards

Carer support and disease

management

Able Sally 71%: c. 24,850

Needs Some Help 17%: c.6,000

Needs More Help 9%: c.3100

Needs A Lot Of Help 3%: c.1050

Sally’s standards

Segmentation, care plans and standards

11

Sally friendly schools

Sally volunteers

Sally Friendly City

Sally friendly supermarkets & businesses

Befriending services

Sally’s StandardsTech and tea

Housing

Transport

Builds on dementia friendly city and maps across to the Social Value Charter

Wellbeing plans

Centre of Contact (single point of access)

Post Discharge Support

Navigation

Remote Telecare

Monitoring

Health coaching

Self Care support

Proactive follow up for people following their discharge from hospital. This could include a phone call within 48 hours of discharge. People at ‘high risk’ of readmission (stage 2 in MDG) would be followed up for 30 days or more.

Guiding people to the appropriate part of the health and social care system to get the support they need. This function could link to a directory of services to support people in accessing local community assets.

Helping people to gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified goals.

Providing people with information about their conditions, promoting healthy behaviours and helping with the emotional impact of chronic illness. People could be followed up over the phone for a specific period to encourage them to be more active participants in their care

This could integrate existing care monitoring systems (e.g. community alarms) and new telehealth solutions, acting as central monitoring hub.

Level 1 - Care Navigator, Directory of Services, PLANS, W2W Portal

Level 2 – Care Navigator Sign Posting and Structured Assessment, Rehabilitation, Reablement and More Specialist Assessment

Health CoachingIncluding

Diabetes Care Call

Redesigned ASS-CT and

Intermediate Care SEP

MDG Post DischargeGP Referrals Emergency Admission New Diagnosis

INBOUND + OUTBOUND CALLSHEALTH COACHINGNAVIGATIONDISEASE MANAGEMENTTELEHEALTH MONITORING

Ambulance GP Intermediate Care services

Integrated Teams Cardiac Rehab Pulmonary Rehab

Telehealth + Telecare + Equipment

Sally and her family, carers

Specialist Support accessed via the Centre of Contact such as: district nursing, podiatry, occupational therapy, heart failure, COPD, diabetes and other services

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Continuum of Proactive Care Services

All adults

Planned for several

years

CCG funded

Rate per

registered patient

NEEDS SOME HELP/

NEEDS MORE HELP

SALLY

Local Commissioned

Service for LTCs*

All vulnerable

adults**

Planned for 1 year:

subject to national

review

NHSE funded

Rate per

registered patient

NEEDS SOME HELP/

NEEDS MORE HELP

SALLY

Enhanced Service:

Avoiding Admissions

Frail elderly:

approx > 65 yrs

Planned for 4

years

ICP/Better Care

Fund funded

Rate per hour for

MDG meetings

NEEDS MORE HELP/

NEEDS A LOT OF

HELP SALLY

Multidisciplinary

Groups (ICP)

>75 year olds

Permanent unless

contract changes

NHSE funded

Part of core

contract

NEEDS MORE HELP/

NEEDS A LOT OF

HELP SALLY

Accountable GP >75

year olds

Last year of life

Permanent unless

QoF changes

NHSE funded

QoF Payment

NEEDS A LOT OF

HELP SALLY

End of Life Care/GSF

Shared care record

Principles

• System shifts from reacting

to anticipating

• Personalised, shared care

planning – Sally at the centre

• Tell your story once, have

one assessment, one key

worker, supported by one

integrated system

• Outcomes driven support

Enablers

• Alliance Agreement

• Pooled fund covering most

health and social care

• Four-year investment and

savings plan (BCF+)

• Workforce development

• Organisational development

• Routine progress review

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Lead Commissioner

P

PP

P PP

Alliance AgreementBENEFITS Full range of services within a single

management arrangement – more effective, efficient and coordinated care

Collaborative environment without the need for new organisational forms

Aligns interests of commissioners and providers, removing organisational and professional ‘silos’ that contribute to fragmented and sub-optimal care

Collective ownership of opportunities and responsibilities; any ‘gain’ or ‘pain’ is linked to performance overall

Supports a focus on outcomes and incentivises better management of population demand

Progressing framework for an integrated care organisation

Commitment to move to all adult population

• CCG, City Council, SRFT, GMW

• Health, social care & wellbeing for 65+ population

• Some services subcontracted

• Includes commissioned 3rd sector services

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Challenges & Critical Success Factors

Challenges

• Implementing change whilst keeping up with today’s work

• Pressures on primary care

• Current model of primary care provision

• Data & information sharing

• Intermediate care- best fit

Success Factors

• Senior leadership

• Governance

• Common vision

• Trust

• Communication

• Function v form

• Carrots and sticks

• Investment in programme management/ operational posts to support the work

Integrated Care -everyone playing their part

Much more than a partnership!