1. Integrating Care for ‘Sally Ford’ and her family – learning from Salford, UK
David Dalton Elaine Inglesby-Burke
Chief Executive Executive Nurse Director

2. Significant population
growth
High levels of need
Poor experience of care
Significant cost of care
Service duplication
National and international evidence
“Integrated health and social care for older people has demonstrated the potential to decrease hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning” Curry and Ham, Clinical and Service Integration – The Route to Improved Outcomes King’s Fund, 2010

3. High demand and rising 34,541 people aged 65+, 28% projected increase
Growth in limiting long-term illness
Disability-free life expectancy
1: 14 have dementia and over-represented in acute beds
2,130 falls related A&E attendances
Growth in people living alone: 12,542 in 2011 to 15,998 in 2030

4. Salford’s approach System shift from reacting to anticipating
Personalised, shared care planning; ‘Sally’ at the centre
Tell your story once, have one assessment, one key worker, supported by one integrated system
Outcomes driven support

5. Primary Drivers Secondary Drivers
Map existing assets within both neighbourhoods
Engage older people to identify those assets that are most valued
Increase access to local community groups
Expand befriending and volunteer support
Develop inter-generational support through working with local schools
Increase prevention and early intervention
Create greater independence and resilience within communities through the increased use of local assets
Achieving greater independence and improved wellbeing for older people in Salford by integrating care within communities
Help older people and their carers navigate services and support themselves through the use of new technologies and the creation of an integrated care hub
Implement solutions that support self care
Implement assistive living technologies
Develop an information portal and directory of services / support
Rationalise the number of points of contact for older people
Provide structured support post discharge from hospital
Develop care navigator role
Risk stratification to identify people at risk of hospitalisation or admission to care homes
Fortnightly multi-disciplinary reviews
Health screening
Develop shared care protocols and shared care plans
Timely management for individuals in a crisis
Establish mechanisms to share information between care providers / professionals
Education and support for individuals and their carers
Increased access to community-based care and support
Increase prevention and early intervention
Deliver a structured approach to population health & wellbeing, with targeted support to those most at risk and their carers, through multidisciplinary working

6. Neighbourhood collaborative
Breakthrough Series Collaborative
7 multi-agency Project Groups
130 people actively involved
Health and social care staff, older people, care homes, voluntary and charitable organisations
Broader stakeholder engagement
Ongoing co-design and testing

7. Integrating care for Sally Ford1
Promoting independence for older people
Better health and social care outcomes
Improved experience for services users and carers
Reduced health and social care costs 3 2
Local community assets enable older people to remain independent, with greater confidence to manage their own care 1
Centre of Contact
acts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring 2
Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support 3

8. Local Community Assets
Carer Support 2
Befriending 1
Way to Wellbeing 3
Local venues 10
Housing & Transport 4
Local Employers 9
Self Care 7
Community Groups 5
Volunteers 8
Telecare 6

9. Centre of Contact (single point of access)
Proactive follow up for people following their discharge from hospital, include a phone call within 48 hours of discharge. People at ‘high risk’ of readmission would followed up for up to 30 days or more.
Providing people with information about their conditions, promoting healthy behaviours and helping with the emotional impact of chronic illness. People could be followed up over the phone for a specific period to encourage them to be more active participants in their care
Post Discharge Support
Navigation
Remote Telecare Monitoring
Health coaching
Self Care support
Guiding people to the appropriate part of the health and social care system to get the support they need, linking to a directory of services to support people in accessing local community assets.
Helping people to gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified goals.
Integrating existing care monitoring systems (e.g. community alarms) and new telehealth solutions, acting as central monitoring hub.

10. Neighbourhood MDGs 7
The MDG meets regularly to review its performance and decide how it can improve its ways of working. Review of pooled or virtual budget. 1 2
Each MDG holds a register of all people who are aged 65 or over. The register is based on the ‘list’ of the federated GP Practices that are members of the MDG.
The MDG stratify the register by risk of hospital emergency admission (and readmission) and admission to care homes. Screening tools are used to identify risk factors. 7
Performance review  1 2 4
Population registry
Risk stratification
Care planning 5
Care and support
Practice nurse
District nurse GP 6
Case conference 3
Social
worker
Community assets
Shared care protocols
Hospital
specialist
Community services
Mental Health 3
Shared care protocols are agreed between all members of the MDG, including End of Life care, multimorbidity and dementia care. 4
An integrated care plan is agreed with each individual. The content varies according to risk and need, but includes a focus on primary and secondary prevention. All individuals are re-assessed though the frequency is determined by their level of risk. 5
Individuals receive care and support from a range of agencies, supported by integrated IT and shared care records. Individuals, their families and carers are supported to play an active role in their own care. 6
A small number of individuals with the most complex needs will be discussed at a multi-disciplinary case conference, to help plan and coordinate their care. Individuals are assigned a key worker to support their needs.

11. Segmentation, care plans and standards
Wellbeing Plan
Sally’s standards
Able Sally 71%: c. 24,850
GP standards
Independence Plan
Needs Some Help 17%: c.6,000
Carer support and disease management
Supported
Independence
Plan
Needs More Help 9%: c.3100
Home care and intermediate care standards
Care Plan
Needs A Lot Of Help
3%: c.1050
Care Home standards
SHARED CARE PLANS
STANDARDS

12. 2020 improvement measures Emergency admissions and readmissions
19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn)
Reduce readmissions from baseline
Cash-ability will be effected by a variety of factors
Permanent admissions to residential and nursing care
26% reduction in care home admissions (from 946 to 699 per 100,000 ppn)
Savings directly cashable but need to be offset by cost of alternative care (especially increased domiciliary care)
Quality of Life, Managing own Condition, Satisfaction
Maintain or improve position in upper quartile for global measures
Use of a variety of individual reported outcome measures
Flu vaccine uptake for Older People
Increase flu uptake rate to 85% (from baseline of 77.2%)
Proportion of Older People that are able to die at home
Increase to 50% (from baseline of 41%)

13. What will be different for Sally Ford and her family?
Greater independence
Able to live at home longer
Reduced isolation
Increased opportunities to participate in community groups and local activities
Confidence in managing own condition and care
Sign-off own care plan and agree who it should be shared with
Support to monitor own health
Know who to contact when necessary
One main telephone contact number for advice and support
Increased community support, specialist care when necessary
Access to a named individual to coordinate care and support
Support to plan for later stages in life
Agreed plan for last year in life

14. Financial and contractual levers
£100 million pooled budget
Four year investment and dis-investment plan
Commitment to reduce acute beds, based on cost not price reduction
Transparency and open book accounting
Alliance Agreement
Collaborative arrangement without need for new organisational forms
Aligns interests of commissioners and providers
Collective ownership of ‘gain’ or ‘pain’
Potential to evolve into a Lead Provider model
Exploring alternative payment mechanisms, including capitation 14

15. Critical success factors
Shared vision: ‘Sally Ford’
Measureable, joint outcomes
Improvement method / testing
Client involvement in redesign
Use of data / integrated records
Structure and pace of implementation
Joint governance and management arrangements
Financial risk and benefit sharing 15

16. WORK IN PROGRESS - DRAFT 14/11/13

17. Table Exercise
Reflect on learning from the four presentations – Key takeaways
10 minutes
Report out – 10 minutes

18. Wrap up and Thank you!!