Alison DavisDirector Integrated Care, North Kent

17th June 14

Integrated Health & Social Care: service transformation supported by technology

• Brief Introduction to the complexities of the Health and Social Care system in Kent

• History of use of telehealth/telecare ,whole system demonstrator and what we learned

• Current agenda including pioneer programme and Better Care Fund (BCF)

• North Kent approach to the Integration of Health and Social Care

Content

Kent & MedwayLocationSea on 3 sides, London suburbsMixture of Affluent, Rural and very deprived areas across the County.

Health andsocial care structure8 CCGs, 1 county council, 12 borough councils, 1 unitary authority, 4 acute hospital trusts

Demographics• Total Population: 1.7m

• Mixture of Affluent, Rural and very deprived areas across the County.

• Better health outcomes when compared to England

• Variation at local level with Dartford, Dover, Swale and Thanet have higher all cause mortality rates.

• Increasing elderly population

• Age 65+ predicted to grow by 9.7% between 2012 and 2016

• 17.3% of the population are aged 65+

• Within the target population, individuals report having an average of 1.6 of the three target conditions of HF, COPD, Diabetes

Advanced Assistive Technology in Kent 2004 The Kent Telecare Pilot1100 users of enhanced Telecare Packages93% felt more independent93% also felt safer in their own homesReduction in residential placements

2005 The Kent Telehealth PilotOne of the first in the UK to formally evaluate AAT and the benefits to the Health economyReduction in A&E AttendancesReduction in unplanned Admissions£1800 average saving per patient over 6 months

2008 -2011 WSD (Telecare & Telehealth)Largest Randomised Control Trial in the World 6000 participantsDecember 1120% reduction unplanned admissions15% reduction in A&E attendances14% reduction in bed days45% reduction in mortality rates.June 12Telehealth reduces Hospital Admissions but unlikely to have a significant effect on costs.Feb 13Telehealth did not improve quality of lifeTelecare has no significant impact on the use of other NHS or social care services

• A better quality of care, lower mortality rates and reduced unplanned hospital admissions are possible

• Patients on the whole like this type of intervention and age is no barrier

• Deploying appropriate technology at the appropriate time to the appropriate patient

• Eligibility criteria and critical mass-technology alone does not bring the change – you need service transformation

• Clinicians key to implementation and success

• Education and training – skilled competent workforce

• Need to Identify an appropriate procurement model to realise cost benefits

What did we learn?

• NHS - over 1 million patient contacts every 36 hours• Increase in Long Term Condition – 1:3 people with a Long

Term Condition • In England over 15 m people have a long term condition with

numbers set to increase in the next 5 to 10 years, especially co-morbidity

• People with long term conditions use 72% of inpatient beds, 68% of out-patient appointments and 55% of GP appointments

• Treatment and care of those with LTCs account for 70% of the total health and social care spend in England, or almost £7 in every £10 spent

• Deliver more for less – increasing demand and financial challenge

The Challenge

I want……. …less time in hospital

…independence

…empowerment

…own bed

…prevention of exacerbation

…in control

…freedom

…more time

…understand own condition

…fewer trips to see specialist

North Kent Vision

“Transformation of the Health & social care system so that it works better for people, with a focus on promoting independence and self care, delivering the right care, right time, right place, providing seamless, integrated care for people, particularly those with complex needs”

• Better access • Increased independence• More control• Improved care at home• Live and die safely at home• Shared care plans

“A single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities”

6 National conditions• Plans to be jointly agreed• Protection for social care services (not spending) • 7 day services in health and social care • Better data sharing between health and social care

based on the NHS number• Assure joint approach to assessments and care

planning, where funding is used for integrated packages of care there will be an accountable professional

• Agreement on the consequential impact of changes in the acute sector

Better Care Fund (BCF)

The Integrated Care & Support Pioneer Programme

• 14 areas selected to lead on health and social care integration.

• Support from the Department of Health and 40 national partners.

• Responsibility to “barrier bust”. • Underpinned by the Better Care

Fund.

Integrated Transformation Components Non Acute bed Provision: Consultant and GP support; Integrated Care Centres; Extra Care; Rehab Units; Community Hospital beds; Private Residential and Nursing bed provision

Crisis Response Services: Access to Shared Anticipatory Care Plans by the ambulance service, enhanced rapid response ,enablement services and voluntary sector based crisis response services.

Integrated Care Home support: Integrated teams including Consultant and GP support; Use of technology to Care Homes / Extra Care Housing providers.

Integrated Equipment , DFGs, capital adaptations & assistive technologies at the front end of all the services video conferencing with clinicians and development of new pathways.

Improved data sharing Promotion of the NHS umber, better health information, use of the health & social care information centre, patients accessing own health records. GPs linked to hospital data.

Operating model: Integrated skill mix, assessors accessing integrated care direct: i.e. nurses accessing social care and case managers nursing care, skills for mental health, dementia/LD a

Integrated Primary Care Teams 24/7 access to multi-disciplinary teams coordinated by the GP, inc mental health/dementia; risk stratifying patients; access to one shared care plan for patient and professionals

Integrated Access: Integrated Locality Referral Unit; 7 days a week direct access and 24/7 crisis response ; Access to one shared care plan on an integrated platform.

Integrated Discharge Teams: Across acute & community; 7 days a week working including Rapid Response; Enablement” Going Home Teams”

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.”

The Future of Health & Social Care

By 2015 • Integrated health and social care teams working 7 days, 24/7 in your

local community.• Your GP as the coordinator of your care, bridging the gap between

your GP, social care, community health services and your hospital. Supported by the community and voluntary sector.

• You will have access to a shared care plan so you and everyone around you know about your care and support.

• Access services through a local referral unit with access to crisis teams and rapid response .

By 2016:• Hospitals without walls. • One team, one estate working towards one budget.• The continued focus on enablement, admission avoidance and crisis

intervention.

New Model of DeliveryPrimary

Prevention

Acute Care

Integ

rated D

ischarg

e TeamIn

teg

rate

d P

rim

ary

Car

e Te

am Voluntary

Services

Housing Telehealth/ Care/ MedicineShared care plans

Psychological Liaison

Discharge Nurses

Case Management

Discharge Planning Teams

Pharmacy

Specialist Services – for example Diabetologist & Respiratory Consultant

Impact/RRFalls

OT/ PhysioSpecialist

NursesGeriatriciansMental HealthEnablement

TwilightAmbulance

10K PopulationGP

District Nurses

30K Population

Dementia Adult Mental Health

Health Visiting

Case Management

Community Pharmacy

Single Point of Access

LRU + LRMS

Measuring Success

• Patient outcome and experience measures (national voices “I” statements)

• Whole system impact – reduction in emergency admissions and social care placements

• Financial sustainability• Individual project performance indicators• New integrated models of commissioning

and procurement.

Any Questions?