Integrating Care for ‘Sally Ford’ and her family – learning from Salford, UK David Dalton Elaine Inglesby-Burke Chief Executive Executive Nurse Director

Significant population growth High levels of need Poor experience of care Significant cost of care Service duplication National and international evidence “Integrated health and social care for older people has demonstrated the potential to decrease hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning” Curry and Ham, Clinical and Service Integration – The Route to Improved Outcomes King’s Fund, 2010

High demand and rising 34,541 people aged 65+, 28% projected increase Growth in limiting long-term illness Disability-free life expectancy 1: 14 have dementia and over-represented in acute beds 2,130 falls related A&E attendances Growth in people living alone: 12,542 in 2011 to 15,998 in 2030

Salford’s approach System shift from reacting to anticipating Personalised, shared care planning; ‘Sally’ at the centre Tell your story once, have one assessment, one key worker, supported by one integrated system Outcomes driven support

Primary Drivers Secondary Drivers Map existing assets within both neighbourhoods Engage older people to identify those assets that are most valued Increase access to local community groups Expand befriending and volunteer support Develop inter-generational support through working with local schools Increase prevention and early intervention Create greater independence and resilience within communities through the increased use of local assets Achieving greater independence and improved wellbeing for older people in Salford by integrating care within communities Help older people and their carers navigate services and support themselves through the use of new technologies and the creation of an integrated care hub Implement solutions that support self care Implement assistive living technologies Develop an information portal and directory of services / support Rationalise the number of points of contact for older people Provide structured support post discharge from hospital Develop care navigator role Risk stratification to identify people at risk of hospitalisation or admission to care homes Fortnightly multi-disciplinary reviews Health screening Develop shared care protocols and shared care plans Timely management for individuals in a crisis Establish mechanisms to share information between care providers / professionals Education and support for individuals and their carers Increased access to community-based care and support Increase prevention and early intervention Deliver a structured approach to population health & wellbeing, with targeted support to those most at risk and their carers, through multidisciplinary working

Neighbourhood collaborative Breakthrough Series Collaborative 7 multi-agency Project Groups 130 people actively involved Health and social care staff, older people, care homes, voluntary and charitable organisations Broader stakeholder engagement Ongoing co-design and testing

Integrating care for Sally Ford 1 Promoting independence for older people Better health and social care outcomes Improved experience for services users and carers Reduced health and social care costs 3 2 Local community assets enable older people to remain independent, with greater confidence to manage their own care 1 Centre of Contact acts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring 2 Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support 3

Local Community Assets Carer Support 2 Befriending 1 Way to Wellbeing 3 Local venues 10 Housing & Transport 4 Local Employers 9 Self Care 7 Community Groups 5 Volunteers 8 Telecare 6

Centre of Contact (single point of access) Proactive follow up for people following their discharge from hospital, include a phone call within 48 hours of discharge. People at ‘high risk’ of readmission would followed up for up to 30 days or more. Providing people with information about their conditions, promoting healthy behaviours and helping with the emotional impact of chronic illness. People could be followed up over the phone for a specific period to encourage them to be more active participants in their care Post Discharge Support Navigation Remote Telecare Monitoring Health coaching Self Care support Guiding people to the appropriate part of the health and social care system to get the support they need, linking to a directory of services to support people in accessing local community assets. Helping people to gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified goals. Integrating existing care monitoring systems (e.g. community alarms) and new telehealth solutions, acting as central monitoring hub.

Neighbourhood MDGs 7 The MDG meets regularly to review its performance and decide how it can improve its ways of working. Review of pooled or virtual budget. 1 2 Each MDG holds a register of all people who are aged 65 or over. The register is based on the ‘list’ of the federated GP Practices that are members of the MDG. The MDG stratify the register by risk of hospital emergency admission (and readmission) and admission to care homes. Screening tools are used to identify risk factors. 7 Performance review  1 2 4 Population registry Risk stratification Care planning 5 Care and support Practice nurse District nurse GP 6 Case conference 3 Social worker Community assets Shared care protocols Hospital specialist Community services Mental Health 3 Shared care protocols are agreed between all members of the MDG, including End of Life care, multimorbidity and dementia care. 4 An integrated care plan is agreed with each individual. The content varies according to risk and need, but includes a focus on primary and secondary prevention. All individuals are re-assessed though the frequency is determined by their level of risk. 5 Individuals receive care and support from a range of agencies, supported by integrated IT and shared care records. Individuals, their families and carers are supported to play an active role in their own care. 6 A small number of individuals with the most complex needs will be discussed at a multi-disciplinary case conference, to help plan and coordinate their care. Individuals are assigned a key worker to support their needs.

Segmentation, care plans and standards Wellbeing Plan Sally’s standards Able Sally 71%: c. 24,850 GP standards Independence Plan Needs Some Help 17%: c.6,000 Carer support and disease management Supported Independence Plan Needs More Help 9%: c.3100 Home care and intermediate care standards Care Plan Needs A Lot Of Help 3%: c.1050 Care Home standards SHARED CARE PLANS STANDARDS

2020 improvement measures Emergency admissions and readmissions 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn) Reduce readmissions from baseline Cash-ability will be effected by a variety of factors Permanent admissions to residential and nursing care 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn) Savings directly cashable but need to be offset by cost of alternative care (especially increased domiciliary care) Quality of Life, Managing own Condition, Satisfaction Maintain or improve position in upper quartile for global measures Use of a variety of individual reported outcome measures Flu vaccine uptake for Older People Increase flu uptake rate to 85% (from baseline of 77.2%) Proportion of Older People that are able to die at home Increase to 50% (from baseline of 41%)

What will be different for Sally Ford and her family? Greater independence Able to live at home longer Reduced isolation Increased opportunities to participate in community groups and local activities Confidence in managing own condition and care Sign-off own care plan and agree who it should be shared with Support to monitor own health Know who to contact when necessary One main telephone contact number for advice and support Increased community support, specialist care when necessary Access to a named individual to coordinate care and support Support to plan for later stages in life Agreed plan for last year in life

Financial and contractual levers £100 million pooled budget Four year investment and dis-investment plan Commitment to reduce acute beds, based on cost not price reduction Transparency and open book accounting Alliance Agreement Collaborative arrangement without need for new organisational forms Aligns interests of commissioners and providers Collective ownership of ‘gain’ or ‘pain’ Potential to evolve into a Lead Provider model Exploring alternative payment mechanisms, including capitation 14

Critical success factors Shared vision: ‘Sally Ford’ Measureable, joint outcomes Improvement method / testing Client involvement in redesign Use of data / integrated records Structure and pace of implementation Joint governance and management arrangements Financial risk and benefit sharing 15

WORK IN PROGRESS - DRAFT 14/11/13

Table Exercise Reflect on learning from the four presentations – Key takeaways 10 minutes Report out – 10 minutes

Wrap up and Thank you!!