Integrated care pilots – Care Without Walls

1. Integrated care pilots – Care Without Walls

2. What is integrated care? Patientcentred • More personal and responsive care Betterhealthoutcomes • Delivers improved health outcomes including quality and patient experience Joint provision • Partnership of providers • Primary, community, secondary, mental health, social care, local government, NHS, third and private sectors Acrossboundaries Systems not structures • Partnerships, systems and models, not only organisations

3. Making it real • Betty is 82, widowed and living alone – her only daughter lives many miles away • She fell recently in the kitchen and called an ambulance – the ambulance men were great and her knee was treated and she’s been promised physiotherapy. She can’t get on a chair anymore to change the light bulbs • She’s been having hearing problems and was due to go to the hospital but the fall meant she missed it • She’s been losing weight recently and stopped cooking her usual hot lunch for herself – she can’t be bothered and is losing confidence to stay in the house she dearly loves • Her daughter’s been trying to help from a distance – she’s been in touch with the GP; put in a call to social services about meals on wheels; re negotiated the missed hearing appointment; and has called twice to see if the physiotherapy appointment’s on its way so she can take a day off to go and drive her to the hospital A Better Way • The local ICO uses a risk prediction model to identify their most vulnerable patients • Betty is selected and accepts a visit from the ICO care coordinator – in this case an experienced District Nurse – who visits on a day Betty’s daughter can be there. • Together they talk about Betty’s health and her worries and draw up a list of all the things that need tackling • Betty accepts the offer of a one stop visit to the surgery to see the community based specialist in elderly medicine; the audiometrist; and the dietician. She’ll have nothing to do with a ‘luncheon club’ • The ICO’s Integrated Falls Team come to the house and fit long lasting energy saving light bulbs; bring Betty’s anti fall slippers; her 24 hour alarm call pendant and put sticky backing on the rug in the hall • Betty’s daughter gets an updated care plan, list of future appointments at the practice and the hospital and a commentary from the nurse – based on her ‘phone calls with Betty - by e-mail every 14 days • Betty’s nurse sends a ‘Be Aware’ alert to the ambulance Trust, local A&E Department and Walk In Centre with her details, Betty’s daughter’s mobile and some background about Betty – it’s entered on their systems

4. What are givens for the pilots? Led by primary and community clinicians Based on GP registered lists Diversity of models Partnership across health and social care providers Innovation Supported by PCT

5. What will we evaluate? 3 Organisational effectiveness • Softer factors influencing success including local relationships, culture 2 Management • How PCTs commission integrated care • Accountability and governance 1 Impact on health outcomes • Improvements in health outcomes • Reductions in health inequalities • Improved quality • Better patient experience

6. So what is the plan? Communicate …to everyone 1 ...hold an inclusive workshop to inform thinking Agree content 2 Select pilots …invite applications, select against criteria 3 Evaluate …ongoing business focused evaluation and shared learning 4

7. Two Journeys Clusters operateas provider partners Good governance New contract for service PRIMARY CARE PROVISION Integrated Care Organisations Compelling case to commissioners Other professions/organisations linked Good governance More delegation Involving otherprofessionals PRACTICE BASED COMMISSIONING Vigorous clinical leadership in commissioning Corporate skills Widening scope of ambition