Leadership For Integration

Who is involved with the project.

Name of Leads∗ Andrew Spooner - GP Lead

∗ Jonathan Griffiths - GP Lead

∗ Shirley Hammersley - Consultant

∗ Susan Ikin – Commissioning Manager

∗ Zoe Ahearne – Community

Matron

Partnership Organisations∗ Cheshire East Council

∗ Cheshire West Council

∗ Cheshire & Wirral Partnership Trust South Cheshire Health

∗ East Cheshire Trust – Cheshire Business unit

∗ Mid Cheshire Hospital FT

∗ North West Ambulance Service

∗ NHS South Cheshire CCG

∗ NHS Vale Royal CCG

∗ Team

∗ Personal

The Journey

∗ Patient centred care (as opposed to disease centred care) with guides to help around the system

∗ Achieving primary care focussed service∗ Patient care delivered in an appropriate part of the system∗ Every person or service doing their own job well -∗ Encouraging and measuring features to work together and

work separately∗ Generic understanding of how to do this for later

dissemination and use

Aims

• 66 year lady, lives with husband (who has some memory loss)

• Has diabetes and heart failure, arthritis• Has many agencies involved, GP,CM, DN, physio, OT,

S.W. continence services • Regular changes in condition; leg oedema, dizziness,

breathlessness, poor renal function, constipation, • Wants to live a active life.

Violet

NHS Outcome Framework (2013-2014)

Prevent people from dying prematurelyEnhancing quality of life for people with LTC

Helping people to recover from episodes of ill health or following injury

Ensuring that people have a positive experience of careTreating and caring for people in a safe environment; and

protecting them from avoidable harm

∗ Care co-ordination∗ Improving primary care management of patients with

both mental and physical health needs through to end of life,

∗ Effective medicine management∗ Managing ambulatory sensitive conditions∗ Active support for self management

Integrated Care

∗ Torbay∗ Northwest London integrated team pilot ∗ Bolton diabetic care∗ Wolverhampton heart failure service ∗ Wales Chronic Care Demonstrators

Examples

In practice ….

Fear of 1% Should not prevent the benefits for 99%

Veterans Affairs Medical Center

∗ Teamlets consistent of ∗ Primary Care Provider∗ Registered Nurse*∗ Health Technician*∗ Clerical Staff Person*

∗ Each member of the teamlet works to the top of their licensure

∗ Optimal functioning of the teamlets depends on the presence of all of these team members

∗ * designates team members who are not present in all teamlets

PACT Teamlets

Access

∗The Big Picture ∗ Bringing together primary, secondary care∗ BIG scale change∗ Aligning services around the needs of the person not

the organisation

Challenges

Change

The Accountable Care Organization is like The Unicorn. A mythical beast with power to cure all our problems, but whom

nobody has ever seen .( A blind man is constructing the unicorn)

What Do We Want To Achieve?