Better Care Fund

Satbinder Sanghera, Director of Partnerships and Governance

What is the Better Care Fund?• Bringing together £3.8 billion nationally into a single

budget for joined up health & social care services

• In Newham the BCF is £22.865m for 2015/16

• We are talking about making it even bigger but is not new money

• One aim is to reduce hospital admissions amongst over 75s

• Intention is to join up health and social care planning in the name of Integrated Care

This integrated care system will deliver nine key interventions

Care coordi-nation

Ensuring patient is in the most appro-priate setting of care

Self-care

Health and social care navigation

▪ Administrative support to ensure patient is following the care plan, that care required for a patient takes place and that a patient is able to secure any appointments required and is actually attending them when needed, across both health and social care

Case management▪ Deliver care and perform detailed review of a patient’s case and condition by GPs,

case manager, or MDTs either in person or remotely to determine any treatments or actions required

Care planning

▪ Conduct joint health and social care assessment of patient needs and jointly create a care plan with patient for care needed , to include goals, required interventions, provider details, and information on who to reach out to in case of need. This should also trigger a request for specific services e.g. falls assessment

Specialist input in the community

▪ Ensure specialists are able to provide support in the community for GPs or to provide input for patients

Self care, behaviour, and expectation management

▪ Empower patients to manage their own condition through provision of tools, education and guidance on behaviours. Clarify expectations in terms of what different services can provide in terms of care

Discharge support from acute to community

▪ Ensure discharge planning starts from day 1, that patients are assessed regularly during their stay, and that all required care packages are in place for when the patient returns home. This will also aim to ensure that post-acute care can happen at home as much as possible, e.g. rehabilitation, or within alternative housing options and that it can be put in place in time for a patient’s discharge

Mental health liaison ▪ Ensure that patients presenting in A&E and on acute wards are adequately

diagnosed for MH comorbidities and referred to the right setting of care. These patients typically include conditions such as alcohol, substance misuse and dementia

Rapid response with short term reablement

▪ Provide an alternative to unnecessary acute and care home admissions by responding to patient’s need in situations of crisis and ensuring that the relevant providers are able to put in care packages quickly to support the patient at home

Discharge support for MH patients from secondary to primary care

▪ Ensure that patients who no longer require specialist MH care are transitioned to primary care and that GPs are empowered to care for them

Joint health, social care, and mental health ap-proach

Improving access to primary care and to various services is critical to ensuring the success of these interventions

What are the nine key interventions?

What changes will I see because of integrated care?Patients GP Practices

Social careHealthcare providers

▪ Own an integrated care plan that outlines what care will be provided to them over the next 12 months

▪ Healthcare professionals better coordinated between different organisations, knowing medical history and what care is being provided by whom

▪ Create care plans for all targeted patients that outline the care they will receive

▪ Shared medical data with other healthcare and social care providers

▪ Able to risk stratify patient population according to their key medical information

▪ Attending case conferences gaining increased expertise and advise on most vulnerable and complex patients

▪ Access to shared view of patients planned care for the year through care plan

▪ Able to view medical information from other providers through IT Tool

▪ Attending case conferences to build relationships with other professionals, offer advise on complex patients and better coordinate their care

▪ Access to shared view of patients planned care for the year through care plan

▪ Attending case conferences to build relationships with other professionals, offer advise on complex patients and better coordinate their care

▪ Act as leaders of MDGs coordinating care for local patient population

Why do we have the BCF?• NHS want to reduce Emergency Admissions

by 3.5%• Implement Rapid Response• Protect local social services activity at a time

of greater need but major savings in local government

• To deliver more services in the community closer to where people live

• To join up Health services & Social care • Improve Patient Experience

Better Care Fund - The Benefits• Better patient experience;• Better clinical outcomes;• Improved productivity;• Care closer to home where appropriate;• This will see organisational benefits that include:• Improvement in health outcomes;• Appropriate levels of A&E attendances; • A reduction of (avoidable) emergency hospital admissions;• Reductions in number of bed days per 1000 patients;• Appropriate level of out-patient referrals;• Improvement in patient experience measures; • New integrated pathways of care e.g. for Diabetes, COPD, and

CVD;• Improvement in self-care.

An integrated care system in Newham will improve patient outcomes and ensure quality care at the minimum necessary costEmpower patients, users and their careers

▪ Enable patients and service users to live independently and remain socially active

▪ Establish education and self-care programmes for patients

▪ Personalise care to patient’s and service user’s needs and preferences1

Provide more responsive, coordinated and proactive care

▪ Proactively manage patient’s health and improve their outcomes

▪ Enable high-quality care that responds to patient/service user needs rapidly in crisis situations

▪ Provide more care in the community or at home

▪ Prevent avoidable admissions and minimise residential care

▪ Leverage tools and technology to deliver timely and better quality of care

2

Ensure consistency and efficiency of care

▪ Deliver the best possible care at minimum necessary costs

▪ Avoid duplication of effort in situations where patient is seen by multiple health and social care providers

▪ Ensure most effective possible use of clinical time and resources3

Where next?

• Better Care Fund in the future will be about how we can work together with the Council, hospitals, GPs, pharmacies to make sure that people get the service they need quickly, close to their home, through one person

• If it works for over 75s with very high risk we will start looking at other groups and see how we can make it work for them