Integrated Care Programme Update December 2014 Chris Badger Assistant Director for Integrated Care

Integrated Care Definition “I can plan my care with people who work together to understand me and my carers, allow me control, and bring together services to achieve the outcomes important to me” - National Voices

Integrated Care Programme Update Better Care Fund Work to date Programme development

Better Care Fund “The Better Care Fund is a single pooled budget to support health and social care services to work more closely together in local areas.” “It provided an opportunity to transform local services so that people are provided with better integrated care and support.” “The Fund will support the aim of providing people with the right care, in the right place, at the right time, including through a significant expansion of care in community settings.” NHS Planning Guidance, December 2013

Make up of fund nationally 2015/2016 (billions) N.B. this is minimum that can be pooled

Local minimum and additional contributions to the Hertfordshire BCF in 2015/16

Better Care Fund April 2014 First submission of BCF plan to NHS England July Revised guidance released. Change in performance- based-pay to one indicator: reduction in emergency admission. Agreed target of 2.5% reduction locally. Full re-draft of BCF plan. Consultation with acute trusts over details of the plan. September 2014 Second submission of revised BCF plan to NHS England Rigorous national review process. Plan approved but further information requested from Hertfordshire ‘Approved with Conditions’. December 2014 Third submission of revised BCF plan to NHS England Feedback due January 2015.

Work to date HomeFirst Stroke Early Supported Discharge Discharge to Assess Community Navigators (West) Complex Care Premium Intelligence and Data Workforce

HomeFirst VIRTUAL WARD Case Management Risk Stratification + Proactive case management (spot problems early) Jointly co-ordinate Health and Social Care Appropriate first contact professional Core assessment document (pt tells story once) Specialist service + voluntary sector involvement Rapid Response Multidisciplinary team (right person) < 60 minute response time (right time) Dedicated homecare (right place) Dedicated Homecare 72 hours dedicated social care support

Stroke Early Supported Discharge Hospital Home Admission Acute Rehab Discharge Rehab Support Current model ESD Service ESD model Rehab Support Rehab Support In ESD model up to 40% discharged early for community rather than bed based rehabilitation

Home to Assess (HtA) Process Pt Admitted to ward H2A SW attends Pt ready for DC Pt Attends A&E Clinical Navigator Hospital SW attends Referral: IDT Completes H2A referral Sent to H2A E-fax number Triage: H2A contacts referrer within 2-4 hours Pt accepted to H2A service H2A contacts Pt within hours Care & Support Plan Review of Plan in 2 weeks Case held by team for 28 days Hospital presentation Ongoing POC SW Support EIT POC no longer needed Case Closed Ongoing POC no ongoing SW support needed Transfer – reviewed annually SCAS

Community Navigators (West only)

Complex Care Premium The Patient Y/N?

Intelligence and Data

Workforce Workstrea m HCT Lead HPFT Lead HCC Lead Acute Lead WS 1: Attraction, Retention, Recruitment WS 2: Workforce Planning WS 3: Workforce Development & Development Infrastructure WS 4: Leadership WS 5: Culture Change & Workforce Transformation WS 6 Workforce Design & Integration Beds & Herts Transforma tion Driver Workforce SupplySkills Development Principles of system wide integration & partnership working Exploration of resourcing strategy for hard to fill vacancies Shared Induction Provision Recruitment Checks - Portability Integrated Learning Pathways (host platform)? Career Pathways across organisations with opportunities for secondments / exchange A Hertfordshire Health and Social Care Leadership Programme? Shared Leadership Competencies? Common Behavioral and Technical Competencies (particularly for Integrated and Multi Disciplinary Teams) Building Community Capacity Appetite for Shared Values and Behaviours Collaborative approach to 7 day working Bands Integrated Roles Possible Policy Review: e.g. Lone Working / Performance Mgt to aid Multi-disciplinary teams Clarity of roles within Multi-Disciplinary Teams

Carers Crossroads care integrated into HomeFirst Stroke specific Caring with Confidence course CCG’s engaged in Carers’ Strategy Carer engagement in all delivery planning

Key Achievements Establishment of new services Ambitious Better Care Fund £10m to support social care from CCGs Development of programme structures and plans Expansion of programme capacity and portfolio of projects Evaluation and continuous improvement of existing projects

Programme and model development Complex High Risk Chronic Conditions Population-wide prevention Enablers HomeFirst Discharge to Assess Complex Care Premium 56% Clinical Navigators Integrated Point of Access 20% Support at home tender Stroke ESD Improving info and advice (Care Bill) 12%