integration in action workshop welcome – angiolina foster cbe director, health and social care...

Integration in Action Workshop

Welcome – Angiolina Foster CBEDirector, Health and Social Care Integration Scottish Government

Integration: yes really!Experience from Fife: Intermediate Care

Fiona MackenzieFife Partnership

Kirkcaldy and Levenmouth CHP

What were we doing?

• Taking a wide range of services across the partnership that had been started over the years, and use them to reshape services in a fully integrated model.

• We call this ICASS – Integrated Community Assessment and Support Service.

• Started in 2009… still work in progress.• Overall aim to provide care at home wherever possible, in an

easily accessible and fully integrated service model.

Integration – The RealityRequired What we have

Increasing activity Resources remain the same or reduced

Easy to access Multiple access points

Integrated design to suit personal outcomes and needs

Separate systems designed to deliver individual organisations aims

Able to respond quickly 5 day service, set up to suit providers

Able to plan an anticipate needs of the most frail

Reactive design with limited structured ACP/Care Manager roles

Designed by users Designed by Services

Pt at Home

Mixing BowlPrevention of Admission

Supporting App Early D/C

IRT

EHCT

CRU

HC

Com Hospital

Com Pharmacy

Sport & Leisure

Carers Trust

Day CareVol Org

Carers

CPN’s

PhysioInt Housing

GP

CRTCAST

DN

SW

COT

Transport

Falls Response

PT

Care Needs Identified

COMMUNITYHOSPITAL

CrisisAnticipatoryNo SPOA

KIRKCALDY & LEVENMOUTH – CURRENT MODEL IC 2009

Just when you have a plan..

• New services come on board - Change Fund .• Intermediate Care comes of age.• Increasingly clear that current model not sustainable = everyone has a

view especially about the role of others.• Partners are responding to issues in own area e.g budget and

emergency access pressures, Council contact centre• Other initiatives get to implementation point, and need to be joined

up coherently.

H@H

Case Management

Assessment, Triage, Inreach to Acute Care, Managing Delays

Home Care, Dementia and Frailty, Community

Rehabilitation

Case Management

35

Integrated Care

Case Management

15

Access PointAdministration

50

20

main actions

• Model how we need to work – relationships always the priority• Leadership group established = one voice.• Access – review and recalculate how teams were working and where

skill mix was needed to reduce admin and duplication of effort for staff

• “Reach in” to acute care to improve decisions and hospital flow• Bring old teams together in new design = pain ++• Ignore boundaries wherever possible

• Simplify language for those outside the system, its difficult enough on the inside.

• Acknowledge future aims e.g have one access point for ICASS and home care.

• Coordinate/ manage the care around the person – explicit role of case manager built in.

• Embed and join up the new roles for people (and there carers) with Dementia and Frailty. Based on 8 pillar model - at last, systematic ACPs as integral part of ICASS.

the good stuff..

• Staff want to improve outcomes – it is what motivates them• When the vision is agreed and others start to see how it fits• Collocation of key staff gave immediate results despite the trauma of

the move.• Use of White Boards and systematic processes eg regular board

rounds involving all of team inc Home care. • Easier to get the right care for the situation using local knowledge and

shared responsibility• If we say everyone matters – we need to act like it.

… and the tricky stuff• Systematic evaluation of complex and cultural change• When things come in left field e.g review of home care ( again),

Hospital at Home introduction.• Data either difficult to collect or not currently available to support

changes – IT systems unable to deliver at present.• Different T&C’s and line management accountabilities. Can be

overcome but not in some critical areas eg. medicines in the community.

• Still essentially 2 + systems involved in developing and delivering integrated model on the ground.

• Would really like to do that but….

and so….

• Hold the Vision• Don’t be fooled into thinking there is a road map for this• Sharpen your compass reading skills• Always design intentionally• Get leaders together and build the relationships • Adapt to whatever comes along – but stick to the vision• “Involve” like your life depends on it – with every stakeholder• Get the data right

Contact

fiona.mackenzie3@nhs.net

thankyou

Please discuss the presentation you have heard and agree on:

1. The single biggest lesson you have learned?

2. One “Do”?

3. One “Don’t”?

Improving Outcomes Through Integrated Working

Older Peoples Services

NHS Forth Valley & Stirling Council

The Improvement Agenda

Aim - Shift balance of care - Support more people to remain at home or return home - Reduce admission to hospital and improve delays to

discharge - Avoid premature admission to care homes

Embarked on whole system approach• Reablement • Rehabilitation at Home• Short Stay Assessment Beds

Outcomes Comparison

2009 2013

Care at home service users

1285 1403

Older people in care homes

670 472

Balance of Care 18% 35%

Cost of care (care at home)

£6.7m £6.7m

Cost of care (Care Homes)

£9.6m £7.3m

Integrated StructureAchievements and Wicked Issues

• Staffing and Culture• Location/Assets• Procedures• Service user contracts and financial impacts• Evidencing impact for individuals

Moving ForwardStirling Care Village

A Health and Social Care Partnership

Residential (34)

Mental HealthRespite

Palliative

Health Beds (32)

Intermediate Care / Rehab / respite (64)

Comm Team Base

Public and Day services“street”

Please discuss the presentation you have heard and agree on:

1. The single biggest lesson you have learned?

2. One “Do”?

3. One “Don’t”?

Integration in Action

NHS Highland

Jan Baird Director of Adult Care

NHS Scotland Event 2013 -

Collaborating for Quality

Boldly Go……….

Lead Agenc

y Model5

YearPlan

1 April2012

Programme Management

Approach Partnership

Working

Professional Leadership

(Practice Governance Framework)

Governance

Case for

Change

Public Communication

Staff Transf

er

WWW

EBI ………. Evidence

/Evaluation – attribution/ contribution challenges

ManagerialReorganisati

on

IT – access not

integrated systemsEvidence

Base

Quantum

EXAMPLES OF HOW THIS IS MAKING A

DIFFERENCE

EXAMPLES OF IMPACT SO FAR

THE

LONG

AND

WINDING

ROAD

BELFORD HOSPITAL

INVERNEVIS

CARE HOME

Please discuss the presentation you have heard and agree on:

1. The single biggest lesson you have learned?

2. One “Do”?

3. One “Don’t”?