1. Developing Integrated care in GM
Building on our Healthier Together Commitments
14th June 2016

2. Context
The Healthier Together made a series of commitments relating to the development of primary and joined up care, (integrated care) across GM. This has given us a platform upon which significant aspects of our GM Strategic Plan, “Taking Charge” has been built. This presentation describes these next steps in the context of the wider GM transformation programme.
Members will recall the “venn diagram” depicting Primary, Integrated and Acute Care and our ambition to achieve a so called “total eclipse” of the Primary and Integrated Care circles. We believe that the work described in this presentation achieves this objective via the development of our GM Locality Plans and their vision for integrated care serving neighbourhoods of circa 30-50k populations.
Scaled, population health and wellbeing management is core to our strategy to transform community based care and support.
This part of our new models of care and support are central to our ability to maximise the demand reducing potential of those new models. An understanding of those characteristics of the new models essential to managing population health improvement and reducing demand on acute services is key to ensuring all parts of GM are developing models which will contribute to clinical and financial sustainability

3. Delivering our ambition: aligning reform across GM
H&SC TRANSFORMATION
WIDER REFORM ACROSS GM

4. Proposed method for a consistent approach to developing an LCO
1. Identify target population
The 10 stage approach to the left starts to illustrate an overall development approach to fully establishing an LCO.
GM colleagues consider the value of consistent approaches at key stages such as:
Risk stratification & population segmentation approaches
how we define an LCOs core characteristics at both a basic and advanced level to reach for the higher ambition on scope and development
A reliable costing methodology inform investment and implementation considerations and
a standard GM approach to Cost Benefit utilising the New Economy model, of interventions delivered by an LCO.
2. Assess potential impact by area of spend
3. Use ‘logic model’ to define reinvestment potential
4. Define core elements of delivery model
5. Translate the core elements to activity
6. Identify and model the workforce requirements
7. Model the financial requirement
8. Conduct segment level Cost Benefit Analysis comparing savings and investment
9. Translate into payment mechanisms
10. Identify performance “dashboard” and approach

5. Key Assumptions & principles
Assets & strengths of people & communities
Equally involved Carers & Family
Integrated Record & Care Plan for health & care needs
Involved in decisions on care & support
Key Assumptions & principles
Use of risk stratification & population segmentation
Well managed needs
2 or more health/complex needs
Mostly Healthy
3 or more health/complex needs
Increasing health and social care needs
Resources & approach reflective of intensity of support required
People & carers empowered to self care
Advice & support
Care & support co-ordination
Integrated team GP
Tailored increase in resources for self-care, carer involvement & primary & social care e.g. longer appointments, same day access, social prescribing, 24/7 cover
Home
pharmacy
GP Practice
Cluster/Group
Better connections of existing teams alongside development of new roles
Mental Health
Physio
Case management
Nurse practitioner
Pharmacist
Clinical lead
Physician associate
Existing services
Specialists
Care Co-ordination
VCSE
New/
emergent roles OT
Behavioural health
Social worker
Extra Care Housing
Diagnostics
JCP
Intermediate Care
Network enablers
Connecting all who contribute to health benefit
Voluntary & Community Sector
Wider Public services (housing, fire etc)
Diagnostics
Community Pharmacy
Primary & social care care at Scale
999,111, OOH
Acute & urgent care
Recognising organisational & cultural development
Cultural & people integration: Human to human, individual to team, team to team - local staff moving towards a single organisation
Financial Integration: Capitated budgets for a defined population with aligned incentives developed within longer term contracts
Systems and operational integration: shared IT & systems supported with robust governance arrangements

6. LCO’s are likely to be made up of interventions addressing these types of issues:1
Prevention and health improvement:
GM and locality programmes such as EY NDM, work and health schemes, dementia utd, Falls.
Improved community and social capital
Asset based care through culture and system change
Work place health programmes
Improved screening and early diagnosis
Use of practice registers and patient level data 2
Population level activity:
Identification (risk stratification and segmentation) and enrolment in programmes of risk individuals 3
Self care, Independence and well being:
Patient activation framework and measures
GM and local social marketing campaigns
Full use of digital technology for better self management and healthy lifestyles
Personal health budgets
Patient empowerment and self management programmes such as expert patient 4
Care planning and care coordination
Care navigation and communication systems across a range of health and care settings 5
Case management 6
Integrated hospital/care home diversion and discharge:
Integrated health and care teams
Access to specialist opinion
Rapid response teams
Virtual wards
Aligned intermediate/reablement 7
A health and care system aligned to wider public services:
Strong partnerships with: education, skills and work
Housing
Voluntary sector 8
New models of pricing and contracting:
Pricing & incentives to drive improvement in population health
Population outcome based contracts for community provision 9
Optimising elective care 10
Better integrated EOLC

7. Summary and recommendations
The Healthier Together Joint Committee is asked to:
Note that the work which initially took place in line with the initial Healthier Together commitments has developed as described in this presentation
Note that this new phase of work directly connects to the GM Strategic Plan, “Taking Charge” and the development of the 10 Locality Plans
Note that each area of GM is developing Locality Care Organisations, in line with the models and characteristics set out in this presentation
Consider, in the light of the above, how the Joint Committee wishes to be appraised of progress on this agenda.