Integrated care pilots – Care Without Walls

NHS Next Stage Review What is integrated care? More personal and responsive care Better health outcomes Joint provision Across boundaries Patient centred Delivers improved health outcomes including quality and patient experience Primary, community, secondary, mental health, social care, local government, NHS, third and private sectors Systems not structures Partnerships, systems and models, not only organisations Partnership of providers

NHS Next Stage Review Making it real Betty is 82, widowed and living alone – her only daughter lives many miles away She fell recently in the kitchen and called an ambulance – the ambulance men were great and her knee was treated and she’s been promised physiotherapy. She can’t get on a chair anymore to change the light bulbs She’s been having hearing problems and was due to go to the hospital but the fall meant she missed it She’s been losing weight recently and stopped cooking her usual hot lunch for herself – she can’t be bothered and is losing confidence to stay in the house she dearly loves Her daughter’s been trying to help from a distance – she’s been in touch with the GP; put in a call to social services about meals on wheels; re negotiated the missed hearing appointment; and has called twice to see if the physiotherapy appointment’s on its way so she can take a day off to go and drive her to the hospital A Better Way The local ICO uses a risk prediction model to identify their most vulnerable patients Betty is selected and accepts a visit from the ICO care coordinator – in this case an experienced District Nurse – who visits on a day Betty’s daughter can be there. Together they talk about Betty’s health and her worries and draw up a list of all the things that need tackling Betty accepts the offer of a one stop visit to the surgery to see the community based specialist in elderly medicine; the audiometrist; and the dietician. She’ll have nothing to do with a ‘luncheon club’ The ICO’s Integrated Falls Team come to the house and fit long lasting energy saving light bulbs; bring Betty’s anti fall slippers; her 24 hour alarm call pendant and put sticky backing on the rug in the hall Betty’s daughter gets an updated care plan, list of future appointments at the practice and the hospital and a commentary from the nurse – based on her ‘phone calls with Betty - by every 14 days Betty’s nurse sends a ‘Be Aware’ alert to the ambulance Trust, local A&E Department and Walk In Centre with her details, Betty’s daughter’s mobile and some background about Betty – it’s entered on their systems

NHS Next Stage Review What are givens for the pilots? Led by primary and community clinicians Partnership across health and social care providers Based on GP registered lists Diversity of models Innovation Supported by PCT

NHS Next Stage Review What will we evaluate? Impact on health outcomes Organisational effectiveness Improvements in health outcomes Reductions in health inequalities Improved quality Better patient experience How PCTs commission integrated care Accountability and governance Softer factors influencing success including local relationships, culture Management

NHS Next Stage Review 1 Communicate…to everyone 2 Agree content...hold an inclusive workshop to inform thinking 3 Select pilots…invite applications, select against criteria 4 Evaluate…ongoing business focused evaluation and shared learning So what is the plan?

NHS Next Stage Review PRACTICE BASED COMMISSIONING PRIMARY CARE PROVISION Two Journeys Clusters operate as provider partners Other professions/ organisations linked Good governance New contract for service Compelling case to commissioners Integrated Care Organisations Vigorous clinical leadership in commissioning Corporate skills Widening scope of ambition Good governance Involving other professionals More delegation