Bernadette Elder – Inspiring Communities Together

Inspiring Communities TogetherNeighbourhood based charity

•Membership led – Trustees elected through membership •Delivers activity – learning and volunteering•Facilitates – bring people together through two local forums• Advocate – link between agencies and local community•Securing resources – paid work linked to aims•Integrated Care – Community Asset theme lead

http://inspiringcommunitiestogether.co.uk

Strategic Context

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Salford Together Partnership•Four high performing partners – within broader network of partners•£98M Pooled Budget - Integrated Care for Older People (ICP)•Governed by Alliance Contract•Underpinned by 2014-18 Service and Financial plan (inc. BCF)•Formal Programme Management approach (ICP)•ICP one of three major transformation initiatives- Out of hospital Care (primary care investment, renewal) & HT

Salford care economy•Urban area in Greater Manchester•Population of circa 230,000•Area of significant deprivation and health inequalities•Largely co-terminus- Salford CGG (health commissioner)- Salford Royal (acute and community healthcare provider)- Salford City Council (adult social care)- Greater Manchester West (mental health provider)

•Long history of successful partnership working

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“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 OutcomesKing’s Fund, 2010

High levels of need

National and international evidence

Significant populationgrowth

Significant cost of care

Poor experience of care

Service duplication

The Start of this Journey…

Salford’s Integrated Care Programme

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

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Local community assets enable older people to remain independent, with greater confidence to manage their own care

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Centre of Contactacts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring

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Promoting independence for older people

Better health and social care outcomesImproved experience for services users and carersReduced health and social care costs

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Housing Workstream

Wellbeing Plan

Care Plan

Independence Plan

SupportedIndependence

Plan

SHARED CARE PLANS

POPULATION STRATIFICATION

STANDARDS

Care Home standards

Home care and intermediate

care standards

GP standards

Carer support and disease

management

Able Sally 71%: c. 24,850

Needs Some Help 17%: c.6,000

Needs More Help 9%: c.3100

Needs A Lot Of Help 3%: c.1050

Sally’s standards

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2020 targets – 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%)

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Lead Commissioner

P

PP

P PP

BENEFITSFull range of services within a single management arrangement – more effective, efficient and coordinated care Collaborative environment without the need for new organisational formsAligns interests of commissioners and providers, removing organisational and professional ‘silos’ that contribute to fragmented and sub-optimal care Collective ownership of opportunities and responsibilities; any ‘gain’ or ‘pain’ is linked to performance overall Supports a focus on outcomes and incentivises better management of population demand

• CCG, City Council, SRFT, GMW, Salix • Health, social care & wellbeing for

65+ population• £98m pooled budget• Some services subcontracted• Phased introduction 2014/15 onwards 8

Alliance Agreement

• Capitalise on our common purpose, strong relationships, and our success

• Extend the vision:

• Population Health Improvement beyond “out of hospital care”

• Single system of governance for health and social care

• Full population list

• Strategic commitment to develop an ‘Integrated Care Organisation’ – initial focus on adults and older people

Integrated Care -> ICO

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Realise the Vision… Objectives

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Integrate commissioning• Single pooled budget across health and social care• Single strategic vision, robust governance & shared decision making• Pathway to single capitated budget

Create an Integrated Care Organisation• Prime provider model• SRFT Lead - direct provision of health and adult social care. Supply chain

Transform and Integrate Primary Care• Investment for renewal – workforce, larger footprint - critical mass, estate• Range of models to involve general practice as a partner

Transform Urgent and Intermediate Care• System redesign, optimal use of estate• Radical shift towards new technology and telemedicine• Preventative, planned care in community and residential settings

Highest quality, safest, most productive H&SC system in England• Shift away from institutional settings• Empowering, anticipatory model of care – delivered in or near the home

Benefits - Outcomes

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Population• More personalised care – in or near the home• Significant reduction in avoidable admissions to hospital and care homes• Improved quality of life for users and carers• Significant increase in the ability of people to manage their own condition

System level• More resilience, flexible governance to target resource around fluctuating need• New relationship with the community – accountable in one place to shape the system

to meet demand with better outcomes, improved experience and greater efficiency• Highest quality, safest, most productive health and social care system in England

Staff• Most attractive workplace in England• Reorganisation around the needs of the citizen• New roles and greater career development opportunities

Implementation Challenges

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Support Salford is interested in accessing•Implementation resource•Due Diligence – Legal Challenges•Liaison with National Bodies – Access to thought leadership e.g. General Practice•Contractual / Payment Systems – risk sharing•Extension of CLASSIC programme

Where Salford can contribute straight away•Integrated Care Programme Management•Alliance Contract Management•Whole system quality improvement e.g. Haelo•Longitudinal evaluation with academic partners e.g. CLASSIC

As a Vanguard Site, Salford is ready to meet the implementation challenges ahead

Community Asset model“Using the knowledge and life experiences of older people to make life better by

listening to and valuing their views: making sure this influences services to be better in future by building on community strengths. This will keep older people

in Salford healthy, happy and independent for longer”

Engagement• The Citizen Reference Group (CRG) This formal structure was established

as part of the ICP programme. The group of local older people are supported through a development worker and meet monthly to look at aspects of the programme – acting as a critical friend. Members engage with areas of work which interest them and act as ambassadors for the programme by sharing key messages from the programme with their own networks.

• The community asset work stream project group have engaged with older people through the network of partners who attend the monthly meetings (housing providers, development workers, third sector organisations, health workers and Salford City Council). Older people are invited to take part in workshops and focus groups to understand what is important to them to support their own health and well being.

Community asset model• An Age Friendly City – the commitment of the city to

support older people to stay healthy and well. • Older Person Standards and Well Being Plans- the

commitment by older people to support their own health and well being.

• A set of tools developed by and for older people based in local neighbourhoods – the commitment of community and deliverers to support older people to stay healthy and well

Community asset work stream project groupThe network includes a wide range of partners including mature people, City Council , University, Businesses, Charities, Social Enterprises, and Third Sector, Work across a number of areas including housing, volunteering, befriending and Leisure and Health Improvement connections.

Community asset approach

• Ensure there is access to advice and guidance for older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being

• Ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity

• Developing technology as a tool for improved health and well being• Building volunteering as a life choice in older age and linking to the

centre of contact and community connectors model• Joining up what is already happening

Cost and value to the NHS• Loneliness = £ to some one who smokes 15 cigarettes

a day • Falls = over 4 million NHS bed days each year • 14% (nearly 5000) of people aged 65 and over may be

at risk of malnutrition (using BAPEN prevalence tool) • Bad oral health leads to poor levels of nutrition & can

lead to social isolation• Technology can be a means to enable older people to

renew and develop social contacts and engage actively in their communities.

BarriersImprovement measures

CA budget 2015/16= £500,000

• Asset mapping – development support to understand what we have and identify gaps and opportunities

• Prevention and well being – Step up programme and advice and guidance including development of tools with older people

• Neighbourhood activity - funding to support access to activity at a neighbourhood level and support new activity

• Technology – tech and tea across the city as a tool for improved health and well being

• Volunteering as a life choice in older ageDelivered by 3rd sector in the community

to support activity already being delivered

Meeting the targetsImprovement measures: •Technology as a tool to increase the proportion of older people that feel able to manage their own long term condition and improve the quality of life for users and carers •Prevention and well being activity ensuring there is access to activity, advice and guidance for older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being. This will help reduce emergency admissions and readmissions.•Neighbourhood activity ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity to increase the proportion of older people that feel able to manage their own long term condition and improve the quality of life for users and carers

Demonstrating the difference

Quality improvement: •A test and learn approach – Small scale test and rapid scale up based on evidence – dash board of measurers:•Loneliness tool•Well being plans•Digital skills•Increase in volunteers•increased community resilience•Improved level of fitness measurers•Increase in awareness of eating well in later life quizHigh level evaluation - CLASSIC: •Improved quality of life measurers

Moving from health to well being

Medical model• Hospital to home – Salford Home Safe• In own home –

– Multi Disciplinary Groups (MDG)– Centre of Contact– GP Surgery

Asset based model• Building on individual strengths• Using the right tools – well being plan/Setting personal goals• Joining up what is already happening and flipping the axis to

support the best outcomes for the person as safely and as quickly as possible

Hospital

CA coordination

group

Medical support

Community assets

WellbeingPlan

Reconnecting individuals to the community

Centre of

Contact

Home Safe

Ready to manage

own health

Home support• Care on call• Health Trainers• Befriending• housing

Hand holding

• Well being coaches

Sign posting

• Health Improvement• Neighbourhood

management

Confidence bld

MDG

GP surgery

Opportunities and challengesOpportunities:•Community Asset approach recognised as part of the solution•Budget allocation – Lowest % at present•Starting to demonstrate impact = £££•VCS as partners in coproduction of modelChallenges:•Moving funding outside the system•VCS working in partnership – Salford approach 3SC (86 members)•Large contracts V small scale neighbourhood interventions

Thank you for listening – For further information

http://www.salfordtogether.comhttp://inspiringcommunitiestogether.co.uk bernadette@inspiringcommunitiestogether.co.uk