1. Objective: Reducing Emergency Hospital Admissions

2. Emergency Hospital Admissions: Risk Factors Age (Babies/very young and older people) Social Deprivation Morbidity (1 or more long term conditions) Area of residence Ethnicity Social factors (Including social isolation) Environmental factors Tools do exist to predict an individuals risk of hospital admission and help us target interventions E.g. RAIDR

4. Better Care Fund: Context Context: – Increasing demand for health and social care services: Ageing population Increasing number of people with one or more long term condition Increasing number of avoidable emergency admissions to hospital Increasingly complex care packages Integrated care – can lead to improved outcomes, improved quality of care and efficiencies Pooling health and social care resources can help to facilitate integration

5. What is the Better Care Fund? Announced in June 2013 Previously known as the Integration Transformation Fund Pooled budget across CCG and Local Authority Funding to be spent on health and social care services based on an agreed plan between the NHS and LA’s BCF plans to be signed off by Health and Wellbeing Boards BCF plans are an integral part of the CCG strategic and operational plans Aims: – closer integration of health and social care services – Improved outcomes for patients, service users and carers

6. The Stockton Better Care Fund Aim: to provide integrated services and pathways of care that help people to stay at home, avoid hospital admission and remain independent for as long as possible Stockton BCF focuses on: –redesigning health and social care services for older people (with a focus on over 65 year olds). By developing integrated Multidisciplinary teams who undertake: –targeted early interventions and preventative approaches –effective crisis management –improving pathways of care for people with dementia - building on the work of the local Dementia Collaborative

7. What could VCS organisations do to support this work? Targeted interventions for those at highest risk of admission. Focused on the following areas: Self-care: supporting those with Long Term Conditions to manage their own condition. Evidence shows this is most effective for some conditions such as COPD and may include: –Education programmes –Telephone health coaching –Encouraging healthy lifestyles –Support for informal care givers

8. What could VCS organisations do to support this work? Cont’d… Preventing social Isolation and loneliness to help maintain independence –Identifying people who are lonely / isolated –One-to-one support including Befriending –Group activities –Support with transport Supporting falls prevention –Identifying people at risk of falls –Strength and balance training –Home hazard assessment and intervention –Referral for a falls assessment Post discharge support –Supporting people to return home / and remain in their own homes following a hospital stay

9. Possible measures of success Reduced avoidable emergency admissions Reduced admissions to long term care Improved discharge from hospital (reducing delayed transfers of care) Maximising the effectiveness of re-ablement to prevent re- admissions to hospital and maximise an individuals independence Improved patient /service user experience Improvements in self reported wellbeing (measured via an agreed tool) Reduced loneliness and isolation Increased fall risk assessments and reduced falls Improved support for carers Increasing the number of people diagnosed with dementia Using the NHS number wherever possible to support evaluation of projects and support future working

10. Sources of further information Preventing loneliness and social isolation among older people http://www.scie.org.uk/publications/ataglance/ataglance60.pdf http://www.scie.org.uk/publications/ataglance/ataglance60.pdf Evidence Summary: Making best use of the Better Care Fund. http://www.kingsfund.org.uk/publications/making-best-use-better- care-fund http://www.kingsfund.org.uk/publications/making-best-use-better- care-fund Link to resourceShort description King’s Fund integration portal Portal of resources on the widespread adoption of integrated care to meet the needs of frail older people and others with complex health and social care needs. ICASEIntegrated Care and Support Exchange (ICASE) is a national resource bringing together practical expertise from national partners, pioneers and the wider health and care system in order to spread and disseminate learning so that integrated care and support becomes the norm rather than the exception. SCIESummary paper by the Social Care Institute for Excellence on preventing loneliness and social isolation among older people. Kings FundEvidence Summary: Making best use of the Better Care Fund. Sam’s StoryJoined up care: Sam’s story. Short animation which brings to life the vision for integrated care from a patient perspective. A Narrative for Person-Centred Coordinated Care National Voices and Think Local Act Personal’s definition of integrated care.