1. Leading and delivering integrated care and services
Mrs Smith
Bob Brown, Director of Nursing and Professional Practice, Torbay & Southern Devon Health and Care NHS Trust.
Florence Nightingale Foundation Conference
27 February 2014

2. What does integrated care mean to us in the context of our current work?

4. Integrated care (N Curry and C Ham, 2013, The King’s Fund)
Three levels of integration MACRO – whole system level integration MESO – integration of services for patients with a particular condition MICRO – coordination of care for individual patients who have complex needs, and carers

5. Integrated Care
‘Care that crosses the boundaries between primary, community, hospital and social care’ (Timmins N and Ham C, 2013)…………….and beyond this to include physical and mental health, housing, education, income.
Services should enable people to take more responsibility for their own health and well-being
As far as possible people should stay well in their own homes and communities
When people need complex care it should be timely and appropriate.

6. National context Two main drivers:
changing demography – cost and complexity
Patient/user/carer experience
Future Forum - Health and Social Care Act 2012
Integrated Care and Support: Our Shared Commitment
Care Bill Dilnott & Francis 2014/15
National Voices opinion

7. What are the barriers to achieving integration?

8. Nuffield Trust (1) Barriers
Slow uptake by some clinicians and limited consequences for non compliance
Lacking line management authority over local providers
Time and resources to change
Development of a single condition service
Benefits not recognised
Inconsistencies in national policy

9. Nuffield Trust and The King’s Fund (2)
Rosen R et al (2011) Integration in Action: four international case studies. The Nuffield Trust
Community Care North Carolina, Greater Rochester Independent Practice Association NYC, Regional Huisatsen Zorg Huevelland Netherlands, North Lancashire Health and Care Partnership
Problems with long term conditions – multiple providers, duplication, inefficiency, poor coordination, poor experience
Six interacting ‘integrative’ processes for aligning incentives and coordinating care – clinical, organisational, informational, financial, administrative, normative

10. Proactively caring for older people and those with complex needs in Sussex (Dr Katie Armstrong and colleagues)
Aim – a seamless and integrated approach: high quality, value for money, whole system
Current barriers to integration –
Grown historically and in an unplanned way
High levels of variation
Poorly aligned with the needs of local patients
Silos - leaving gaps in care pathways
Duplicate processes, such as assessments
Too many ‘hand overs’ of care – confusion
Too many patients inappropriately in acute beds
Systems are too reactive and hospital-centric
Staff become disillusioned

11. Sussex (2) The clinical pathway Staying healthy
Proactive community care
Admission avoidance (a mark of quality)
In-hospital care
Regaining and maintaining independence
Delivery
One team
Effective communication and leadership
Risk stratification
Specialist support around core team
Community Geritricians
Core MDT functions
Comprehensive and holistic single assessment
Wrap care around the patient – care coordination
Care planning owned by the patient and carer
Care delivery is single and integrated
Support people in crisis and when admission is required
Support patients to be safely discharged from hospital
Sussex (2)

12. What are the integration enablers?

13. What will enable integration success?
One health and care system
Every £ for the benefit of the system
Common focus on right care, right place, right time, right person
Everyone can be a leader of the system
How will we know?
Population health will improve
Our community will report good experience of the system
Our staff will tell us this is a good system to work in
We will report an increasing amount of evidence to demonstrate that integrated care is working.

14. Nuffield Trust (3) Enablers Governance and incentives
A web based clinical portal
Integrated electronic information system
Standards developing leadership – trust and respect – full involvement – single vision
Multiprofessional teams supporting care coordination, case management and review of selected high risk patients

15. Torbay and S Devon: Our local care landscape
Below average earnings, pockets of real deprivation.
More age-related conditions such as dementia.
Above average smoking, drinking, domestic abuse, teenage pregnancy in some areas.
Issues such as access to services, isolation.
All require holistic approach - not just medical treatment.

16. Rurality factor
c.375,000 residents
extra 100,000 in summer

17. The Future Model of Care
Risk
Need
Independent
Dependant
Safe
Unsafe
Primary
Community
Acute
Dependant
Moderate Dependence
Minimal Dependence
Independent
Crisis
Regular intervention
Independent
e.g. elective procedures / outpatients, uni-professional need / single issue, ill -health prevention and wellness, housing, education
Minimal dependence
e.g. Managed conditions/ stable, e.g. COPD, Diabetes, MND, CFSME, risky behaviour loneliness, isolation, mental health, carers issues
Moderate dependence
e.g. planned care, in a safe place (e.g. wards or bed based)
MDT, ABI, Intermediate Care
Dependent
Urgent e.g.
A&E, EDS, CRT, Safeguarding
Early intervention
Prevention

18. The Integrated Care Pathway (Sussex model, Armstrong K et al)
Self-Care
Hospital Care
Primary Care
Staying Healthy
Proactive Community Care
Admission Avoidance
Maintaining Independence
In-hospital Care
Discharge
Community Care

20. Where is the best progress being made?

21. What has been studied and where?
International and UK specific integrated care research over a number of years
Most familiar are USA models – Kaiser Permanante, Veterans Health Administration, Geisinger Health (different funding model to UK)
2011 research and most aligned to the NHS = 4 studies on high quality ,cost effective ICOs – North Carolina, New York, Holland and North Lanarkshire Health and Care Partnership
Most aligned to proposed Torbay model = Inner North West London ICO pilot
There are other ICO models in the UK but some have not been subjected to rigorous independent scrutiny.

22. Success Factors from North London ICO
New case management and care management did not reduce acute admissions in year 1
Increase in early diagnosis of dementia and improved management of mental health
Develop right metrics at the outset
Integrated IT solutions vital to capture activity
Improved co-ordination of care for older people and those with LTC’s
Reduction of duplication and handoffs
Improved patient / user experience in all settings
Improved collaboration and communication between teams and between professionals
Improved diagnosis and monitoring 22 22

23. Steventon A et al (2011) An evaluation of the impact of community based interventions on hospital use, a case study of 8 Partnership for Older People projects POPP. Nuffield Trust

24. Summary findings
No evidence of a reduction in emergency hospital admissions
Support workers for community matrons had no impact on hospital use
An intermediate care scheme increased the number of emergency admissions and bed days
Health and social care working together can reduce the number of bed days following admission
Rapid response service reduced outpatient attendances
An assessment and signposting service increased emergency hospital admissions

25. Nuffield Trust (4)
Shaw S and Levenson R (2011) Towards integration in Trafford. The Nuffield Trust Focus – bringing together primary and community care, acute medicine, specialist outpatient and diagnostic care into a new community based ICO (integrated care organisation)

26. Nuffield Trust (5) How did they achieve integration in Trafford?
Meaningful collaboration across professional groups has been critical
Six multidisciplinary clinical panels responsible for redesigning services
A locally tailored international leadership programme
A single vision, patient and public involvement
Outcome based service evaluation
Appropriate use of technology and effective data sharing
Proof of concept year, then spread.

27. South Eastern HSC Trust, Northern Ireland
Long-term conditions strategy from 2013:
Risk stratification – working with primary care
Prevention and health promotion – active patient programme
Professional practice – roles and leadership
Integrated working – Integrated Care Partnerships, Community Ward
SQE and Innovation – Impact and outcomes; learning network with the Basque country.

28. The YAS Clinical Hub – Angela Harris, Lead Nurse, Urgent Care

29. What Pathways do we use? GP and GP Out Of Hours
District Nurse/Rapid Response Teams
Falls Teams
Minor Injury Units
Social Services Emergency Teams
Mental Health Crisis Teams

30. Focus after the earthquake to create ‘one system’
The quest for integrated health and social care, Canterbury, NZ (Timmons N, Ham C, The King’s Fund, 2013)
Focus after the earthquake to create ‘one system’
Community Rehabilitation Enablement and Support Team CREST
An electronic shared care record - single portal
Impact – 2011/12 demand for aged care grew by 7%, while CREST enabled a reduction in bed utilisation by 6% (13% saving); A&E attendances reduced by 4% (60-80 year olds)

31. The King’s Fund (2013) Integrated Care in NI, Scotland and Wales
Structural integration will only bring benefits if accompanied by:
A single outcomes framework
Governance arrangements that enable different organisations to develop joint strategies
Political, managerial and clinical leadership at all levels
Organisational stability
A willingness to challenge and overcome professional culture and behavioural values
A commitment to integrated care as a policy priority
Sharing information across and between health and social care

38. Nurses as integrated care leaders?

39. Person-centred leadership
‘Wards in Mid-Staffs lacked strong principled and caring leadership’ (Robert Francis QC)
The links between patient experience, staff motivation and wellbeing (Maben et al 2012)
Building teams that gel – face challenges together
Facilitate greater staff empowerment
Building resilience by creating support and supervision
Building a supportive local ‘care’ climate
Set a positive emotional tone for care delivery.

40. Engaging leadership (Alimo-Metcalfe B 2012)
A model of leadership that is open, accessible and transparent…emphasises team work, collaboration and connectedness
Removing barriers to communication
Status quo is challenged
Ideas are listened to and valued
Innovation and entrepreneurialism are encouraged

41. ‘Leadership is a moral and emotional activity
‘Leadership is a moral and emotional activity. It is about the ability to engage, motivate, inspire. It is defined by our values and implies moral courage, integrity, conviction to accept accountability’.

42. Not a short journey………(Baker, 2008) Consistent leadership Continuous quality improvement Develop our staff Engage our community Primary care at the centre Seamless transitions Information to guide improvement Keep learning