1. Delivering integrated care in Thanet
Welcome!
Delivering integrated care in Thanet
Hazel Carpenter Accountable Officer for Thanet Clinical Commissioning Group gave the presentation.
19th May 2016

2. Stakeholders identified some principles of IC Thanet
Person centred
Keeping people well - prevention
Managed care - care is actively managed, one care plan that is followed by everybody
Organisation - clear and consistent funding, value for money
Location - looked after locally
Care is integrated – multi professional, one team
First contact – always get the right service
Multispecialty Community Provider Model
A new care model with better access to care, extended primary care team proactively managing need, and an integrated team which includes specialist advice and increased support in the community.

3. This slide just gives more detail on the principles of the care model – I just want to draw your attention to the first box entitled membership
A very clear message that came out of the initial workshops was that this was about all of us all of the time. This would be a membership organisation made up of the public, GP’s, Nurses, care staff etc – stakeholders at the workshops were keen that there would be a great sense of ownership and therefore responsibility, and that it was not necessarily about providing services but that people would be supported to take responsibility for their own health and wellbeing – as individuals and communities.

4. Our Vision
This is our vision for Thanet that we work together:, one team, one service a shared budget.

5. Single Integrated Care Record
Practice
Single Integrated Care Record
Localities.
4 Localities.
30 – 50k patients.
Integrated Teams.
Tiers of care:-
Preventative
Case Load
Integrated Care
Hub.
Front ending A&E / Ambulatory Care / Acute Response Team.
Tiers of care:-
Reactive Advice
Reactive Visit
Virtual Ward / access to beds
Practice
Practice
This fits with the national innovation and change which is being taken forward by vanguards – our nearest is in Whitstable, whilst here in Thanet we may be working on a similar scheme but under a different title: ’Primary care at Home’. But essentially it allows our GP practice members to work together in groups of practices to test this idea of extending and integrating the care we offer out of hospital, as well as the looking at those times when you urgently need support from the hospital and how that could be improved.
Practice
Practice

6. Our Vision – Adult Social Care
Where people live
Centred around the individual - “a life not a service”
Through transition on an all age pathway
House slide
KCC have over the last 2 years been transforming their services across the whole of the County focusing on best use of existing resources, efficiency and effectiveness and improving outcomes for people.
They have now aligned their older peoples services with CCG boundaries. The transformation of social care has to continue but KCC are now ready to look at alternative commissioning and provision models that fully integrate with the NHS this year – this is one of our key priorities for 16/17
Our Integrated model is focused on supporting and promoting independence and wellbeing and ensuring optimal health and outcomes for people. Work will be centred around the individual and not around a service.
Supported by building blocks

7. Individual Pathway / Journey (primarily for Older People)
Care navigators / Community agents signposting and building community capacity
Integrated OT service accessing equipment and assistive technologies
OT led rapidly responding integrated reablement linked to paramedic service
Nurse led outcome focussed homecare (new joint roles created)
So the individual older persons journey will include care navigators/community agents who will signpost and build community capacity. Integrated OT services to assess and support and rehabilitate older people at the earliest opportunity maximising their independence and reducing reliance on services. All working as part of the community team along with GP’s, Nurses and domicillary workers.
Integrated care pathway
Single patient record
‘one’ team around the GP
Support to care homes