1. Healthier Communities and Older People Scrutiny Panel 7 October 2009 Tony Fraher Transformation Programme Director

2. Transforming Care Policy Drivers Elements Fit with Intervention model & Care system design

3. Policy Drivers Putting People First Personalisation and linked themes

4. … choice and control should extend to individuals in every setting and at every stage; ranging from advocacy and advice services, prevention and self-management to complex situations where solutions are developed in partnership with professionals … recognise the ability of individuals to identify cost effective, personalised solutions through wider community networks and innovation. … an enabling framework to ensure people can exercise choice and control with accessible advocacy, peer support and brokerage systems with strong links to user led organisations … supported decisions built on appropriate safeguarding arrangements, eg risk boards and corporate approaches to supporting individual choice and risk management. Supported by a network of “champions”, including volunteers and professionals … A local care workforce with the capacity and capability to deliver choice and support individual control Policy Drivers DH Local Authority Circular 1 (2009)

5. Transforming Care Elements Personalisation (Choice & control ) Integrated frontline delivery Integrated Organisation ( Workforce/OD) Integrated Information & Accessibility Community support & provider market options

6. Low to moderate needs Citizenship Information Lifestyle Practical support Early intervention Enablement Community support for LTC Institutional avoidance Timely discharge General population Complex needs Substantial needs Involvement of older people Tackling ageism – positive images Equal access to mainstream services Making a positive contribution, including volunteering “ No door the wrong door” Single point of access, self assessment, peer ‘navigators’ Active ageing initiatives Public health messages, including diet and smoking Peer health mentoring Befriending and counselling Shopping, gardening etc Case finding and case management of those at risk Intermediate care services Enablement services – developed from home care Hospital in-reach and step down pathways Post discharge support, settling in and proactive phone contact Integrated or co-located teams and/or networks Generic workers Case finding and case management of complex cases / LTC end of life care – enabling people to die at home Management of unscheduled care Choice & Control:- people receiving self directed support, including direct payments and individual budgets Dignity: - Dignity challenge and ‘champions’ Carers: - carers receiving assessment, specific carers services, information, Expert Carers Programme Home and community Community safety initiatives, including distraction burglary Locality based community development Population ‘needs’ Example interventions Fit with Intervention Model Making the links for transformation ( Acknowledgement Nick Marcangelo CSIP CAT )

7. AIMS Intermediate Tier Re-ablement Bed/home/RR Single Point of Access 75% resolution : Advice Signposting Low level intervention Transfer to complex case Management in locality teams Triage ‘filter’ in AIMS, with handover for Assessment/intervene/resolve. For Acute/Community referrals Inc.Rapid response Home in-reach to DPoWH Generalised Community Access, Intervention & Resolution Out reach to community Complex Cases Management (specialist) Transfer Fit with Care System Design

8. Transforming Care Organising the Programme Programme Board / Reference Group Programme Blueprint & structure Pathfinder Workshops / working groups

9. Programme Outcomes - What will be better? These are the things we define as the programme outcomes and will evaluate to demonstrate the programme has delivered Access to wide-ranging integrated information on support options ( inc.self funders ) Access to appropriate support via all parts of the health, social care and wider support system Being central ( with family ) to defining need/issues and outcomes Personal budgets to use to meet agreed outcomes in support plan / lifeplan Informed/supported choices in how to meet desired outcomes Integrated response to complex/LTC Safe and effective sharing of information between professionals that reduce duplication of questions and to provide a coordinated response Single point of contact in multi-disciplinary care Transforming Care

10. (1) Models of care, processes, structures and systems that enable us to deliver transformed care Projects Universal information and accessibility Personalisation – Self-Directed Support Personalisation – Personal Health Budgets Integration – Common Assessment Framework Things we need to do:-

11. Market shaping Social Capital development Community Engagement Engaging “system” partners ( Acute /GP ) Culture change Staff engagement Workforce Development Fit with other CTP Programmes Inward looking Outward looking Transforming Care Things we need to do:- (2) Changing the “environment” to enable us to deliver transformed care

12. Models of care, Process, Systems, Structures Environment Stakeholder engagement Measures Themes Projects SDS ( RAS/IB etc ) Personal Health Budgets Brokerage model AIMS ( low level brokerage/support )   = Linked programmes Pathfinder ( info sharing, IT, CAF etc ) High level prevention ( stop complex )  Complex case management  Intermediate Tier redesign  Assistive Technologies “No door wrong door!” experience AIMS ( info/signposting )  Outcomes. performance, efficiency Voluntary, community, ULOs  Workforce development OD / Culture change Community Engagement Strategy Communications Acute Trust & GP engagement Information & accessibility Informed ( supported ) Choice Integrated interventions - Choice & control at every setting/every stage. - “boundary-less” transit Market ( Support Choices ) Workforce development Purpose Outcomes Transforming Care Purpose, themes, projects & linked projects

13. Projects Universal Information & Access Integrated Delivery ( CAF ) Self Directed Support Personal Health Budgets Workforce development Culture Change/OD Communications

14. Self Directed Support Information/ Advice/ Guidance 1 st Contact/ Screening Assessment Reablement/ Further Assessment Rapid Response Assessment RAS Support Planning Brokerage Care & Support Delivery Review Reassessment SDS Operating Model

15. What happens now when people ask for help: Assessment by professionals Decision about eligibility Care plan developed by professionals Care plan starts and is monitored & reviewed Changes made as required What is “self-directed support”?

16. Under self-directed support what happens: Person completes self- assessment questionnaire as part of wider assessment Person told allocation of funds Person develops “Support Plan” with desired outcomes “Support Plan” agreed by authority Monitoring & review focuses on outcomes rather than inputs or services Changes made as required What is “self-directed support”? (2)

17. Among the challenges... Self-directed support involves taking risks Professional roles will change Culture has to change Providers will have to become even more flexible “CHANGE” What did the evaluation say?

18. Running workshops for key staff on changes required Developing policies & procedures, e.g. self-assessment questionnaire & resource allocation system (RAS)‏ All new assessments include self- assessment questions People eligible for help are being offered personal budgets As at 21 September, 60 people were getting help with social care through self-directed support Evaluation of implementation to date to be completed by end December 2009 North East Lincolnshire Care Trust Plus is also taking part in a national pilot to introduce self-directed support in the NHS What’s happening in North East Lincolnshire?