Presentation on theme: "Leading and delivering integrated care and services"— Presentation transcript:
1 Leading and delivering integrated care and services Mrs SmithBob Brown, Director of Nursing and Professional Practice, Torbay & Southern Devon Health and Care NHS Trust.Florence Nightingale Foundation Conference27 February 2014
2 What does integrated care mean to us in the context of our current work?
4 Integrated care (N Curry and C Ham, 2013, The King’s Fund) Three levels of integration MACRO – whole system level integration MESO – integration of services for patients with a particular condition MICRO – coordination of care for individual patients who have complex needs, and carers
5 Integrated Care‘Care that crosses the boundaries between primary, community, hospital and social care’ (Timmins N and Ham C, 2013)…………….and beyond this to include physical and mental health, housing, education, income.Services should enable people to take more responsibility for their own health and well-beingAs far as possible people should stay well in their own homes and communitiesWhen people need complex care it should be timely and appropriate.
6 National context Two main drivers: changing demography – cost and complexityPatient/user/carer experienceFuture Forum - Health and Social Care Act 2012Integrated Care and Support: Our Shared CommitmentCare Bill Dilnott & Francis 2014/15National Voices opinion
8 Nuffield Trust (1) Barriers Slow uptake by some clinicians and limited consequences for non complianceLacking line management authority over local providersTime and resources to changeDevelopment of a single condition serviceBenefits not recognisedInconsistencies in national policy
9 Nuffield Trust and The King’s Fund (2) Rosen R et al (2011) Integration in Action: four international case studies. The Nuffield TrustCommunity Care North Carolina, Greater Rochester Independent Practice Association NYC, Regional Huisatsen Zorg Huevelland Netherlands, North Lancashire Health and Care PartnershipProblems with long term conditions – multiple providers, duplication, inefficiency, poor coordination, poor experienceSix interacting ‘integrative’ processes for aligning incentives and coordinating care – clinical, organisational, informational, financial, administrative, normative
10 Proactively caring for older people and those with complex needs in Sussex (Dr Katie Armstrong and colleagues)Aim – a seamless and integrated approach: high quality, value for money, whole systemCurrent barriers to integration –Grown historically and in an unplanned wayHigh levels of variationPoorly aligned with the needs of local patientsSilos - leaving gaps in care pathwaysDuplicate processes, such as assessmentsToo many ‘hand overs’ of care – confusionToo many patients inappropriately in acute bedsSystems are too reactive and hospital-centricStaff become disillusioned
11 Sussex (2) The clinical pathway Staying healthy Proactive community careAdmission avoidance (a mark of quality)In-hospital careRegaining and maintaining independenceDeliveryOne teamEffective communication and leadershipRisk stratificationSpecialist support around core teamCommunity GeritriciansCore MDT functionsComprehensive and holistic single assessmentWrap care around the patient – care coordinationCare planning owned by the patient and carerCare delivery is single and integratedSupport people in crisis and when admission is requiredSupport patients to be safely discharged from hospitalSussex (2)
13 What will enable integration success? One health and care systemEvery £ for the benefit of the systemCommon focus on right care, right place, right time, right personEveryone can be a leader of the systemHow will we know?Population health will improveOur community will report good experience of the systemOur staff will tell us this is a good system to work inWe will report an increasing amount of evidence to demonstrate that integrated care is working.
14 Nuffield Trust (3) Enablers Governance and incentives A web based clinical portalIntegrated electronic information systemStandards developing leadership – trust and respect – full involvement – single visionMultiprofessional teams supporting care coordination, case management and review of selected high risk patients
15 Torbay and S Devon: Our local care landscape Below average earnings, pockets of real deprivation.More age-related conditions such as dementia.Above average smoking, drinking, domestic abuse, teenage pregnancy in some areas.Issues such as access to services, isolation.All require holistic approach - not just medical treatment.
16 Rurality factorc.375,000 residentsextra 100,000 in summer
17 The Future Model of Care RiskNeedIndependentDependantSafeUnsafePrimaryCommunityAcuteDependantModerate DependenceMinimal DependenceIndependentCrisisRegular interventionIndependente.g. elective procedures / outpatients, uni-professional need / single issue, ill -health prevention and wellness, housing, educationMinimal dependencee.g. Managed conditions/ stable, e.g. COPD, Diabetes, MND, CFSME, risky behaviour loneliness, isolation, mental health, carers issuesModerate dependencee.g. planned care, in a safe place (e.g. wards or bed based)MDT, ABI, Intermediate CareDependentUrgent e.g.A&E, EDS, CRT, SafeguardingEarly interventionPrevention
18 The Integrated Care Pathway (Sussex model, Armstrong K et al) Self-CareHospital CarePrimary CareStaying HealthyProactive Community CareAdmission AvoidanceMaintaining IndependenceIn-hospital CareDischargeCommunity Care
21 What has been studied and where? International and UK specific integrated care research over a number of yearsMost familiar are USA models – Kaiser Permanante, Veterans Health Administration, Geisinger Health (different funding model to UK)2011 research and most aligned to the NHS = 4 studies on high quality ,cost effective ICOs – North Carolina, New York, Holland and North Lanarkshire Health and Care PartnershipMost aligned to proposed Torbay model = Inner North West London ICO pilotThere are other ICO models in the UK but some have not been subjected to rigorous independent scrutiny.
22 Success Factors from North London ICO New case management and care management did not reduce acute admissions in year 1Increase in early diagnosis of dementia and improved management of mental healthDevelop right metrics at the outsetIntegrated IT solutions vital to capture activityImproved co-ordination of care for older people and those with LTC’sReduction of duplication and handoffsImproved patient / user experience in all settingsImproved collaboration and communication between teams and between professionalsImproved diagnosis and monitoring2222
23 Steventon A et al (2011) An evaluation of the impact of community based interventions on hospital use, a case study of 8 Partnership for Older People projects POPP. Nuffield Trust
24 Summary findingsNo evidence of a reduction in emergency hospital admissionsSupport workers for community matrons had no impact on hospital useAn intermediate care scheme increased the number of emergency admissions and bed daysHealth and social care working together can reduce the number of bed days following admissionRapid response service reduced outpatient attendancesAn assessment and signposting service increased emergency hospital admissions
25 Nuffield Trust (4)Shaw S and Levenson R (2011) Towards integration in Trafford. The Nuffield Trust Focus – bringing together primary and community care, acute medicine, specialist outpatient and diagnostic care into a new community based ICO (integrated care organisation)
26 Nuffield Trust (5) How did they achieve integration in Trafford? Meaningful collaboration across professional groups has been criticalSix multidisciplinary clinical panels responsible for redesigning servicesA locally tailored international leadership programmeA single vision, patient and public involvementOutcome based service evaluationAppropriate use of technology and effective data sharingProof of concept year, then spread.
27 South Eastern HSC Trust, Northern Ireland Long-term conditions strategy from 2013:Risk stratification – working with primary carePrevention and health promotion – active patient programmeProfessional practice – roles and leadershipIntegrated working – Integrated Care Partnerships, Community WardSQE and Innovation – Impact and outcomes; learning network with the Basque country.
28 The YAS Clinical Hub – Angela Harris, Lead Nurse, Urgent Care
29 What Pathways do we use? GP and GP Out Of Hours District Nurse/Rapid Response TeamsFalls TeamsMinor Injury UnitsSocial Services Emergency TeamsMental Health Crisis Teams
30 Focus after the earthquake to create ‘one system’ The quest for integrated health and social care, Canterbury, NZ (Timmons N, Ham C, The King’s Fund, 2013)Focus after the earthquake to create ‘one system’Community Rehabilitation Enablement and Support Team CRESTAn electronic shared care record - single portalImpact – 2011/12 demand for aged care grew by 7%, while CREST enabled a reduction in bed utilisation by 6% (13% saving); A&E attendances reduced by 4% (60-80 year olds)
31 The King’s Fund (2013) Integrated Care in NI, Scotland and Wales Structural integration will only bring benefits if accompanied by:A single outcomes frameworkGovernance arrangements that enable different organisations to develop joint strategiesPolitical, managerial and clinical leadership at all levelsOrganisational stabilityA willingness to challenge and overcome professional culture and behavioural valuesA commitment to integrated care as a policy prioritySharing information across and between health and social care
39 Person-centred leadership ‘Wards in Mid-Staffs lacked strong principled and caring leadership’ (Robert Francis QC)The links between patient experience, staff motivation and wellbeing (Maben et al 2012)Building teams that gel – face challenges togetherFacilitate greater staff empowermentBuilding resilience by creating support and supervisionBuilding a supportive local ‘care’ climateSet a positive emotional tone for care delivery.
40 Engaging leadership (Alimo-Metcalfe B 2012) A model of leadership that is open, accessible and transparent…emphasises team work, collaboration and connectednessRemoving barriers to communicationStatus quo is challengedIdeas are listened to and valuedInnovation and entrepreneurialism are encouraged
41 ‘Leadership is a moral and emotional activity ‘Leadership is a moral and emotional activity. It is about the ability to engage, motivate, inspire. It is defined by our values and implies moral courage, integrity, conviction to accept accountability’.
42 Not a short journey………(Baker, 2008) Consistent leadership Continuous quality improvement Develop our staff Engage our community Primary care at the centre Seamless transitions Information to guide improvement Keep learning