1. Berkshire West 10 Frail and Older People Pathway Redesign Programme
South Reading Patient Voice Group
Stuart Rowbotham; Director of Adult Social Care, Wokingham Borough Council

2. Meeting aims To share with Reading Patient Voice:
the work undertaken as part of the Frail and Older People Project
the key findings to date of the project
the next steps in developing services

3. Programme aims
To build on the model of care developed with the Kings Fund in 2014 by:
creating a person centred, joined up response to meet Sam’s needs;
improving the experience of older people living in our communities;
enhancing the navigation of services across our system; and
using scarce resources more efficiently in the face of growing demand.

4. Progress to date Care Model Financial Model
Carried out a gap analysis comparing the current pathway against “Sam’s Story”;
Identified 11 areas of focus for improvement;
Reviewed evidence of best practice against these 11 areas;
Developed initial assumptions for testing through the financial model.
Financial Model
Collected available data from all organisations involved in the current pathway;
Developed and analysed a detailed baseline of current service provision;
Produced a first draft 5 year projection.

5. Care Model Design Living well What if I become unwell?
What if I have health needs?
What if I become unwell?
What if I need urgent help?
What if I am admitted to hospital?
What if I’m at the end of my life?
Primary prevention – health education and screening
Carer support
Connecting and signposting to local community and activities
Primary Care led models of proactive intervention – anticipatory care planning and risk stratification
Effective medicines management
Engagement with primary prevention services ( isolation, housing mobility and nutrition)
Adaption, equipment and practical support in the home
Comprehensive assessment of needs and support, falls prevention, meds optimisation and screening
Identified care co-ordinator
Support and advice from secondary care
NHS111 – advice, triage and care navigation
Rapid assessment and support from local teams including Primary care, Community Pharmacists, MH, Social Care and specialist clinicians
Access to reablement/adaptions and aids
Use of teleheath/Telecare
Access to 24/7 rapid response admission avoidance services which include near patient testing/monitoring and treatment initiation
Rapid senior clinical assessment ( Geriatrician of the day) and on the day discharge home where possible
Assertive in-reach
Integrated Care and Assessment - use of Trusted assessment and early discharge to step down/time to assess beds
Rapid access to advice and support
Use of advanced care planning
Additional wrap around support from primary and community/social care and VS services

6. Frail Elderly Pathway Programme - Logic Model
Design Principles
A commitment to personalisation, choice and co-production
Recognition of accountability and local democratic decision making processes
Transparency of decision making
Pro-active engagement with key stakeholders
Balancing the need for locality approaches with evidenced benefits of initiatives at scale
Assessment and clear articulation of overall benefits and risks at organisational and population levels
Workforce and Technology considerations to include whole sector including primary care and the care sector
Deliverables of the Programme
Agreed system wide pathway model which aligned to the 5YFV
Agreement to adopting and converting the preferred operating model including necessary delegations, and organisational structural changes needed
An economic model which sets out the impact of the new model across the system drawing out opportunities and risks
What good looks like
Active Screening and early identification of risk factors
Annual health checks and medication reviews
Use of comprehensive geriatric assessment where appropriate
Adoption of single Trusted assessment and use of care planning by all sectors
A single health and care shared patient record
Use of combined personal health and care budgets
Use of telehealth (cardiac, respiratory and diabetes)
Use of near patient testing
Virtual board rounds in the community for targeted groups and those most at risk
Direct referral to services and for diagnostics by professionals without the need to refer back to the persons GP
Consistent use of personal recovery guides/service navigators for both patients and carers
Expanded use of social prescribing
Rapid access to out of hospital urgent care health and care services within 2 hours
Consistent use of discharge to assess models
Increased use of Ambulatory care models
Expected Outcomes of New Model
Increase in numbers of people who feel supported to manage their LTC
Reduction in spend on inappropriate hospital based care and conveyances to hospital
Reduction in spend on long term nursing and residential care
Increase in spend on extra care accommodation and time to assess beds
A increasingly skill mixed workforce which includes expanded use of the voluntary sector
An enhanced role for NHS111 taking complexity out of the system for the public
A model of Primary and Community Care which optimises capacity through the use of technology, different roles and integrated MDTs
Key Measures
Reduction Attendances at A&E
Reduction in numbers receiving long-term community-based care
Reduction in avoidable inpatient activity for people with Ambulatory Care conditions
Increase in proportion of people using health and social care who receive self-directed support, and those receiving direct payments
Increased in the proportion of people dying at home/place of their choosing
Reduction in hospital admissions among users of specialist mental health services – split by elective and
emergency admissions
Use of payment models which incentivise collaboration between providers and increased efficiency and high quality care are delivery which is outcomes focused

7. Next steps.
Agree the target changes in activity levels and financial impact modelling
Identify the service operating model and early quick wins or development opportunities for 16/17
Map and establish the links with NHS and Local Authority related projects
Primary Care Strategy and local plans
Better Care Fund Plans
CCG Operating Plans for 16/17
Wider system Workforce Strategy
Connecting Care and expanding technology enabled care
CCG Transformation Board work programmes