Collaborative Care Initiatives for Over 75s: Exploring Effective Strategies

1. Background Update on Over 75s • CCG keen to explore collaborative working through a LES mechanism • One of functions of the Fed is to facilitate collaborative working • Fed looked at schemes which are • Practical • Impact practice workload • Evidence based • Some schemes attractive but difficult to implement in short term e.g. • Home visiting service – cannot recruit NPs on 1 to 2 year contracts • Assertive Community Treatment for mental health – need mental health trust to lead

2. Proposal for discussion • Of initial £2.50, £1.62 plus 36p to practice schemes • Special Patient Notes – 42p • Yellow folders – 42p • Visits to housebound with LTCs – using model developed by SBS – 42p plus 36p • Of initial £2.50, 88p to collective schemes • InstantCare • Discharge coordinators • Outcome £2.50 – all to practices, no Fed top slicing • 32 practices want to look at Fed proposal, 6 DHG practices working together, 3 doing own thing

3. Special Patient Notes Patients with SPN 50% less likely to require an ambulance and 80% less likely to be referred to A&E If all practices achieved level of Haven Health = additional 3,233 notes = 90% increase

4. Implementation plan • Fed dealing with paperwork – no action needed by practices for now • Submissions made to trigger £2.50 payment less the 88p • May/June • Public engagement plan developed • Practice delivered schemes - Fed work-up detailed implementation packs and organise training if needed • InstantCare should be able to start early • Recruit discharge support teams • July – services commence • Regular feedback to practices • Discuss at future shutdowns