The Kings Fund and Pioneer Communities Kernow CCG Governing Body June 2013 Joy Youart

Case for change Increasing demand from older people Unsustainable in current system Patients not seen in most appropriate place Avoidable delays Continuing healthcare over-subscribed Leadership summit has prioritised Older people = 80% of GP activity

Kernow one of 10 national learning sets Learning and sharing ideas, best practice Clinical leadership Influencing national policy Large scale, fast-paced change Details 5 sessions of shared learning at the Kings Fund 3 days on-site time from an expert from the Kings Fund A workshop on integrated care for older people for clinicians and operational staff

Support older people at home Enhanced support at home Frail Elderly Pathway – Care standards (time based) Self care Input in acute setting Support older people at home Enhanced support at home Support Older People at Home Manage Crisis Effectively Manage step down from acute effectively Enhanced support at home Self care All standards relate to patients assessed as being ‘frail’ Home/care home Crisis Acute Trf of care Home/care home Std H1. All patients remotely identified as an emerging risk (by e.g. the Devon tool) will be assessed* within 7 days Std C1. For all patients identified as being at risk of admission to an acute hospital, an assessment *will be initiated within 2 hrs of the request Std A1. On arrival in ED / admissions unit, all elderly patients at risk of adverse outcomes will be ISAR scored within 4 hrs . Std T1. All patients will be transferred to the most appropriate care setting following a decision of ‘medically fit for discharge’ as follows: Standards to be developed David Oliver model for frail elderly – shared via Kings Fund Note – model may be extended for other groups: children, other people with long term conditions Note: David has been a practising hospital doctor for 24 years and a consultant, specialising in geriatric and general internal medicine, for 15 years. He has been lead clinician and clinical director for both South London NHS Trust and the Royal Berkshire NHS Foundation Trust. He was the government’s National Clinical Director for Older People’s Services at NHS England Std H2. Primary care will respond to a request for a GP visit and make a ‘treat/refer/admit /no action’ decision within 4 hrs Std A2. Patients with an ISAR score of 3 or more will be notified to the CGA case manager and assessed*within XX hrs Std C2. All patients in crisis will start to receive a package of enhanced support at home within 2 hrs of the need being identified. NB working patterns T1a. For first time care home placement: Arrival by 17.00 within XX days of the decision Std A3. All patients in hospital will be assessed* before they leave hospital. HOLD pending D2A discussions T1b. For return to care home: Arrival by 21.00 if decision by 14.00. By 12.00 next day if decision after 14.00 Std C3. Within XX hrs of the need being identified for a Community bed, all patients in crisis will be transferred to that bed * All assessments are carried out using a Comprehensive Geriatric Assessment (CGA) approach T1c. For assessment bed / I.C. bed: Arrival within 24 hrs between 10.00 and 16.00

Pioneer Communities Expression of interest: Health and Social Care Integration Pioneers Builds on learning: brings in expertise Data analysis Modelling Health economics Contract design Workforce advice National political support Norman Lamb MP Health minister

What’s on offer? Consideration of freedoms and flexibilities at national level Support to address local barriers Commitment to look at changes to national rules Expertise, but no funding Even if we don’t get chosen, the process of documenting our potential, commitment and aims for integrating care and support will help to galvanise the economy into a single, shared and collectively delivered vision.

Delivery Full delivery Agreed model Immediate local change One extra patient, per practice, per week, cared for in an appropriate setting = money released for lower cost, community based alternatives Immediate local change Agreed model Full delivery Five years Max two years October 2013 Building on work already in our programmes We are doing many of the right things, we just need to coordinate our efforts Freedom to test cash-releasing ideas