Leading and delivering integrated care and services Mrs Smith Bob Brown, Director of Nursing and Professional Practice, Torbay & Southern Devon Health and Care NHS Trust. Florence Nightingale Foundation Conference Twitter @bobjbrown 27 February 2014

What does integrated care mean to us in the context of our current work?

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

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-being As far as possible people should stay well in their own homes and communities When people need complex care it should be timely and appropriate.

National context Two main drivers: changing demography – cost and complexity Patient/user/carer experience Future Forum - Health and Social Care Act 2012 Integrated Care and Support: Our Shared Commitment Care Bill Dilnott & Francis 2014/15 National Voices opinion

What are the barriers to achieving integration?

Nuffield Trust (1) Barriers Slow uptake by some clinicians and limited consequences for non compliance Lacking line management authority over local providers Time and resources to change Development of a single condition service Benefits not recognised Inconsistencies in national policy

Nuffield Trust and The King’s Fund (2) Rosen R et al (2011) Integration in Action: four international case studies. The Nuffield Trust Community Care North Carolina, Greater Rochester Independent Practice Association NYC, Regional Huisatsen Zorg Huevelland Netherlands, North Lancashire Health and Care Partnership Problems with long term conditions – multiple providers, duplication, inefficiency, poor coordination, poor experience Six interacting ‘integrative’ processes for aligning incentives and coordinating care – clinical, organisational, informational, financial, administrative, normative www.nuffieldtrust.org.uk/integratedcare

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 system Current barriers to integration – Grown historically and in an unplanned way High levels of variation Poorly aligned with the needs of local patients Silos - leaving gaps in care pathways Duplicate processes, such as assessments Too many ‘hand overs’ of care – confusion Too many patients inappropriately in acute beds Systems are too reactive and hospital-centric Staff become disillusioned

Sussex (2) The clinical pathway Staying healthy Proactive community care Admission avoidance (a mark of quality) In-hospital care Regaining and maintaining independence Delivery One team Effective communication and leadership Risk stratification Specialist support around core team Community Geritricians Core MDT functions Comprehensive and holistic single assessment Wrap care around the patient – care coordination Care planning owned by the patient and carer Care delivery is single and integrated Support people in crisis and when admission is required Support patients to be safely discharged from hospital Sussex (2)

What are the integration enablers?

What will enable integration success? One health and care system Every £ for the benefit of the system Common focus on right care, right place, right time, right person Everyone can be a leader of the system How will we know? Population health will improve Our community will report good experience of the system Our staff will tell us this is a good system to work in We will report an increasing amount of evidence to demonstrate that integrated care is working.

Nuffield Trust (3) Enablers Governance and incentives A web based clinical portal Integrated electronic information system Standards developing leadership – trust and respect – full involvement – single vision Multiprofessional teams supporting care coordination, case management and review of selected high risk patients

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.

Rurality factor c.375,000 residents extra 100,000 in summer

The Future Model of Care Risk Need Independent Dependant Safe Unsafe Primary Community Acute Dependant Moderate Dependence Minimal Dependence Independent Crisis Regular intervention Independent e.g. elective procedures / outpatients, uni-professional need / single issue, ill -health prevention and wellness, housing, education Minimal dependence e.g. Managed conditions/ stable, e.g. COPD, Diabetes, MND, CFSME, risky behaviour loneliness, isolation, mental health, carers issues Moderate dependence e.g. planned care, in a safe place (e.g. wards or bed based) MDT, ABI, Intermediate Care Dependent Urgent e.g. A&E, EDS, CRT, Safeguarding Early intervention Prevention

The Integrated Care Pathway (Sussex model, Armstrong K et al) Self-Care Hospital Care Primary Care Staying Healthy Proactive Community Care Admission Avoidance Maintaining Independence In-hospital Care Discharge Community Care

Where is the best progress being made?

What has been studied and where? International and UK specific integrated care research over a number of years Most 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 Partnership Most aligned to proposed Torbay model = Inner North West London ICO pilot There are other ICO models in the UK but some have not been subjected to rigorous independent scrutiny.

Success Factors from North London ICO New case management and care management did not reduce acute admissions in year 1 Increase in early diagnosis of dementia and improved management of mental health Develop right metrics at the outset Integrated IT solutions vital to capture activity Improved co-ordination of care for older people and those with LTC’s Reduction of duplication and handoffs Improved patient / user experience in all settings Improved collaboration and communication between teams and between professionals Improved diagnosis and monitoring 22 22

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

Summary findings No evidence of a reduction in emergency hospital admissions Support workers for community matrons had no impact on hospital use An intermediate care scheme increased the number of emergency admissions and bed days Health and social care working together can reduce the number of bed days following admission Rapid response service reduced outpatient attendances An assessment and signposting service increased emergency hospital admissions

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)

Nuffield Trust (5) How did they achieve integration in Trafford? Meaningful collaboration across professional groups has been critical Six multidisciplinary clinical panels responsible for redesigning services A locally tailored international leadership programme A single vision, patient and public involvement Outcome based service evaluation Appropriate use of technology and effective data sharing Proof of concept year, then spread.

South Eastern HSC Trust, Northern Ireland Long-term conditions strategy from 2013: Risk stratification – working with primary care Prevention and health promotion – active patient programme Professional practice – roles and leadership Integrated working – Integrated Care Partnerships, Community Ward SQE and Innovation – Impact and outcomes; learning network with the Basque country.

The YAS Clinical Hub – Angela Harris, Lead Nurse, Urgent Care

What Pathways do we use? GP and GP Out Of Hours District Nurse/Rapid Response Teams Falls Teams Minor Injury Units Social Services Emergency Teams Mental Health Crisis Teams

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 CREST An electronic shared care record - single portal Impact – 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)

The King’s Fund (2013) Integrated Care in NI, Scotland and Wales Structural integration will only bring benefits if accompanied by: A single outcomes framework Governance arrangements that enable different organisations to develop joint strategies Political, managerial and clinical leadership at all levels Organisational stability A willingness to challenge and overcome professional culture and behavioural values A commitment to integrated care as a policy priority Sharing information across and between health and social care

Nurses as integrated care leaders?

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 together Facilitate greater staff empowerment Building resilience by creating support and supervision Building a supportive local ‘care’ climate Set a positive emotional tone for care delivery.

Engaging leadership (Alimo-Metcalfe B 2012) A model of leadership that is open, accessible and transparent…emphasises team work, collaboration and connectedness Removing barriers to communication Status quo is challenged Ideas are listened to and valued Innovation and entrepreneurialism are encouraged

‘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’.

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