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Integrated care programme

Integrated Care: Integrated Community Services for Adults Cath Doman Head of Community Health Commissioning Programme Lead Integrated Care NHS Airedale, Bradford and Leeds Lyn Sowray Assistant Director Adult and Community Services Bradford Metropolitan District Council.

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Integrated care programme

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  1. Integrated Care: Integrated Community Services for AdultsCath DomanHead of Community Health CommissioningProgramme Lead Integrated CareNHS Airedale, Bradford and LeedsLyn SowrayAssistant DirectorAdult and Community ServicesBradford Metropolitan District Council

  2. Integrated care programme • Delivering the vision for integration • Transformation of health + social care in the District • Integration of community services clustered around GP practice/s • Services working as a single team for each locality • Risk stratification of locality population

  3. In simple terms, it’s… …whatever the person needs following (or to prevent) acute care or long-term dependence • Reablement • Rehab • Recuperation • Return to optimal health + wellbeing

  4. The visionRight careright placefirst time Joined up services to enable people to regain and keep their optimal health, well-being and independence

  5. The health economy • Need for new models of care delivery • Funding gap • Shift from hospital to community requires greater capacity and productivity in community services • Growing demand/population requires a preventative approach • Increased capacity to prevent needs escalating • Better case management across partners to reduce bureaucracy, duplication, risk Adapted from slide by Nick Morris BDCT

  6. The Partners Commissioners • NHS Airedale, Bradford and Leeds • Emerging Clinical Commissioning Groups • BMDC • NYCC (for Craven) Providers • Bradford District Care Trust • Bradford Teaching Hospitals • Airedale NHS FT • Bradford Metropolitan Borough Council • Voluntary and Community Sector • North Yorkshire County Council

  7. Integrated functions • Community nursing • Intermediate care services • Community therapy services • Long-term conditions management • Long-term support and care • Rehabilitation and reablement • Associated support services - VCS • Opportunities to include MH + LD services

  8. The programme Mental health and dementia Enable

  9. Dr Tom Downes 2008

  10. Timescale: 2-3 years Practices putting in proposals now • 2011/12 Transfer + achieve consensus Transfer of community services and development of strategy • 2012/13 Change Early wins: test-sites across District of teams working together, common criteria, assessment and records, enablement working alongside therapy and community nursing • 2013/14 Polish + make it stick 111, pooled budged, single management, health + social care services delivered from community-based hubs

  11. Warden Discharge team CMHT GP Introducing Mrs Jones… District nurse Housing grants Community Matron Physio podiatrist Out-patients Equipment services Social worker OT Practice nurse Social services OT Home care Heart doc Diabetes doc MATS BDCT BMDC InCommunities BTHFT ANHSFT VCS GP

  12. Discussion and questions

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