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Rochdale Better Care Fund
Plan 2016/17
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PLAN DETAILS a) Summary of Plan
Local Authority Rochdale
Clinical Commissioning Groups Heywood Middleton and Rochdale
Date agreed at Integrated Commissioning Board:
12th April 2016
Date agreed at Health and Well-Being Board: To be confirmed
Date submitted: 21st March 2016
Total agreed value of pooled budget: 2016/17
£18,096,240
Sign Off and Approval
Signed on behalf of the CCG NHS Heywood Middleton and Rochdale CCG
By Chief Officer Simon Wootton
Signature
Date
Signed on behalf of the Council Rochdale Metropolitan Borough Council
By Director of Adult Social Care Sheila Downey
Signature
Date
Signed on behalf of the Clinical Commissioning Group NHS Heywood Middleton and Rochdale CCG
By Chair of CCG Dr Chris Duffy
Signature
Date
Signed on behalf of the Health and Wellbeing Board Rochdale Health and Well Being Board
By Chair of Health and Wellbeing Board Cllr Janet Emsley
Signature
Date
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1.0 The local Vision for Health and Social Care Services
Our vision for health and social care and wellbeing by 2021 is set out in Rochdale GM
Devolution Locality Plan ‘Co-operating for better Health and Wellbeing: A plan for 2016-21.
Section 1.3 Where we want to be.
In order to achieve our vision we will prioritise the following:
1. Extending lifestyle and behaviour change programmes – aiming to have an impact at
the earliest possible time.
2. Strengthening community engagements and ownership of health and wellbeing,
building more opportunities for community and peer support, developing new
solutions and support mechanisms alongside public services.
3. Growing early years and early intervention support, targeting children and adults at
risk before problems take root.
4. Extending local mental health and wellbeing services, with individuals and community
groups becoming a strong part of the support available.
5. Integrated the commissioning of health, care and wellbeing so that services are put in
place to meet the needs of the person.
To achieve this transformation we will pool resources and jointly commission services across
health and social care, concentrating on the needs of the whole person in the design of
services, using co-production as our default way of working.
Our new models of care and support focus investment in new ways of supporting people,
placing greater emphasis on self-care, peer support, prevention, screening and informed and
shared decision making.
By doing the above, we believe this will reduce demand for planned and emergency health
and care services as more people choose more solutions closer to home, or choose to
manage their health care conditions in a different way.
2.0 An evidence base supporting the case for change
Please refer to Rochdale Borough Locality Plan, Section 1.2 Where we are now and section
1.2.1 -The case for change describes the opportunities to improve quality and reduce costs.
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3.0 A coordinated and integration plan of action for delivering that change
Rochdale Integrated Commissioning Board was set up in October 2015 as part of the
revised Governance arrangements. This Board received monthly assurance and updates on
the BCF progress and achievement of the targets during 2015/16. The actions and reports
were then submitted to the Health and Wellbeing Board as the statutory board for
responsibility.
There are a number of Better Care Fund work streams that were set up in the first year of
the plan. The Integrated Care Steering Group (meets bi-weekly), BCF performance, finance
and activity and the Integrated Care Record task and finish group that meets monthly. It is
expected that these groups will remain in place in some form to ensure delivery of the
requirements of the BCF and will report within the new governance arrangements proposed
within the Rochdale locality plan.
The Integrated Commissioning Board will oversee the delivery of the GM Rochdale locality
plan as set out in Section 2.1.4 Governance and programme management.
A section 75 agreement is already in place and this will be revised and updated in line with
the BCF budget and plan for 2016/17.
4.0 A clear articulation of how our plan meets each national condition
4.1 Plans to be agreed jointly
The Better Care Fund planning 2016/17 has been presented to the Integrated
Commissioning Board whose membership consists of Local Authority, CCG and Public
Health representation with Governing Body members and Cabinet portfolio holders.
4.2 A demonstration of how the area will maintain the provision of social care services
in 16/17
Local adult social care services will continue to be supported within the same manner as
15/16 via the same allocation £8.217m funded from the CCG minimum allocation.
4.3 Delivery of 7 day services across health and social care to prevent unnecessary
admissions
Rochdale has committed to providing 7 day services through its newly commissioned models of care. The new Intermediate Tier of Care service, the largest scheme of the Better Care Fund in 2015, mobilised on the 1st September 2015. This has already demonstrated an impact in improved patient outcomes and length of stay.
This new Intermediate tier service is already a fully integrated health and social care service that is delivering demonstrable and significant results, with a single vision, operating model and outcomes. The new model has increased the social care packages of care to allow enhanced support up to 4 times a day enabling late afternoon discharges.
Rochdale has also undertaken a competitive tender process for our community neighbourhood healthcare services known as Integrated Neighbourhood Teams which is due to go live 16th May 2016. This will also be delivered through a provider partnership led by Pennine Acute Hospitals, Integrated Community Division.
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RAID services are commissioned 24/7 in A&E departments and older people inpatients service which also enables 7 day access and discharge arrangements.
7 day extended access to primary care services went live in Rochdale in December 2015. Section 2.5 of the Rochdale Locality Plan, describes the new Primary Care service model which will include the development of integrated health and social care hubs across our Borough. 4.4 Better data sharing between Health and Social Care
During 2015/16 Rochdale Health and Social Care were exploring the implementation of the Integrated Care Record (ICR) locally and as part of the North East Sector Integrated Care Record project. Across Greater Manchester Rochdale, Oldham and Bury were the only local CCGs that don’t yet have an established an integrated care record offer. The work on the ICR has been on-going for some 18 months now and a decision has now been reached. This is the only national requirement that Rochdale Health and Wellbeing Board constantly submitted a ‘working towards’ response during BCF 2015/16. Rochdale is 97% compliant in use of the NHS number as the primary identifier. Rochdale has opted for the same model as Wigan CCG and LA which is the Medical Interoperable Gateway (MIG) solution. This is a local and North East Sector project and the solution is fully interoperable with partners across primary care , community, out of hours, hospital, local authority and the ambulance services. The chosen solution is also compatible with any GM solution proposed as part of the Greater Manchester Devolution.
The MIG (Medical Interoperability Gateway) has been decided upon from working across Greater Manchester and taking learning and best practice from other HWBBs. The support will be delivered by Healthcare Gateway who will integrate data derived from disparate Consortium feeder systems and present relevant information in the format of a shared record view.
There will be 3 stages to this work:
The MIG will allow secure and easy access to other partner organisations going forward to
share care
1) A local focus on collaboration with Rochdale Local Authority – this will involve a Read-
Only view of data being passed between GP and LA systems. Stage 1 will be led by an
Integrated Care project team.
2) A North East Sector focus to consume and share data from Oldham GP’s\LA, Bury
GP’s\LA, Pennine Acute, Pennine Care, BARDOC and Go-To-Doc. Stage 2 is currently in
planning stages.
3) A Greater Manchester collaboration – the MIG will share data into any solution put
forward across GM.
The data sharing agreements have been managed and controlled by the North East Sector IG and IMT working groups and have been signed off by the Local Medical Committee and the Solicitors. Once all these have been completed the anticipated launch date for the MIG is expected to be June 2016.
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The Greater Manchester Combined Authority and partners (GM) plan to establish a GM wide transformational data sharing capability across public services. In line with the Health and Social Care integration strategy, which has made information sharing its top priority, GM recognises that data sharing is a key pillar to enable the transformation of public services. Data sharing will enable the provision of more integrated, proactive, timely and tailored services to individuals, improving their experience and well-being and supporting more effective and targeted management of GM’s resources: delivering savings, efficiencies, and improved outcomes. GM’s data sharing vision: To create value and insight across GM: supporting improved and more efficient services and improved outcomes for GM and residents, by breaking down information silos and barriers to sharing data, will support GM’s wider vision to be a leading example of efficient integrated public services, establishing GM as a truly connected city and region and a great place to live and work.
GM’s vision is to be at the forefront of data innovation and collaborative working across UK public services. The deliverables outlined in section 4 will be transferrable to other councils and, in addition, the technology platforms and user/ resident portals which will form the later deliverables of the programme can also be re-used. This work will support the continued development of legislation around data sharing, providing practical guidance and robust data security platforms that enable a more appropriate balance between data privacy and data sharing. 5.0 An agreed approach to financial risk sharing and contingency
The CCG and LA have both agreed that there is no risk share agreement. The risk-share arrangement in 2015/16 related to the successful procurement and mobilisation of the Intermediate Tier service. 6.0 Joint approach to assessments and care planning (accountable professional)
Multi- disciplinary team (MDT) meetings are already in existence across Heywood, Middleton & Rochdale GP practices and are the centre of providing local integration with health and social care. The newly commissioned integrated health and social care teams will mobilise on 16th May and there will be a process in place to agree a lead professional as part of the joint review and joint planning of identified patients to support the reduction in unnecessary admissions to hospital by improving preventative clinical care and managing complex conditions. In addition to the above, in future all people over 75 will have a named GP, funded through the CCG development programme. This will allocate additional funding for all older people in the borough, and, where relevant, the GP will take the role as lead professional in coordinating their care. This will particularly be the case where older people have high level needs and/or are identified as being particularly at risk of hospitalisation. The MDT meeting provides a forum in which the integrated teams can engage in the joint process to assess risk and plan care but, as with identifying risk, the team members can initiate a discussion at any time. Patients with a high or escalating risk of admission are reviewed, and an MDT case management plan is developed and mobilised. Patients identified by this process are admitted onto the caseload or virtual ward, with their needs fully assessed and reviewed as part of MDT meetings until they are stepped down to the most appropriate level of care within the wider integrated health and social care team.
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All patients are allocated a named care co-ordinator at MDT meetings, who is accountable for ensuring that the care plan and agreed interventions are delivered by the various team members. This person could be any of the MDT members, depending on the patient’s primary needs. While the GP remains medically accountable for all patients identified in a primary or community care setting, the GP is currently rarely the named care co-ordinator, as it is not always practicable to oversee multiple and complex interventions from a wide range of people. The model of the integrated care team includes a voluntary sector worker to both assess needs for support from the third sector, as well as contributing to holistic care planning and provision of low-level support as appropriate. Team members will liaise with wider community teams, for example with mainstream mental health services, so that the most appropriate specialist support and advice can link with the integrated team care coordinator. The integrated team will allocate a lead professional to ensure that all care planning is patient-centred and co-ordinated with all professionals involved. The integrated care teams, and in particular the mental health nurses in the teams, have established links with hospital-based mental health services as well as community based teams like mental health intermediate care teams and community dementia liaison services to facilitate seamless support for people with mental health problems. Rochdale currently has the Proactive Care programme in place across all GP practices have (Unplanned Admissions Enhanced Service). This enhanced service is designed to help reduce avoidable unplanned admissions by improving services for vulnerable patients and those with complex physical or mental health needs, who are at high risk of hospital admission or re-admission. This programme will be embedded in the new models of primary care in 2016/17 as set out in the locality plan in 2016/17.
7.0 Agreement on the consequential impact on the providers
The lead provider of the Intermediate Tier is the local acute trust community health and
social care division. Through the activity and contract reporting the partnership is able to use
this evidence base internally to influence the commissioning and contracting discussions on
the acute contract activity with the Trust. These discussions have already been factored into
the 16/17 planning round.
8.0 Agreement to invest in NHS Commissioned out of hospital services, or retained
pending release as part of the local risk share
The Intermediate Tier service is commissioned on an outcome based incentivised contract
for 5 years on a 3 + 2 year basis. The new model has already demonstrated a reduction in
admissions in the first quarter September 2015- December 2015. Please refer to the
Rochdale Borough locality plan Section 2.1 page 38 – Case Study, New Integrated
Intermediate Tier services.
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9.0 Agreement on local action plan to reduce DTOC and improve patient flow
High Impact Change Model – Managing Transfers of Care Heywood, Middleton, Rochdale Economy
Impact Change Where are you What do you need to do When will it be done by
How will you know it is successful
Early Discharge Planning
Currently inconsistent application of Expected Date of Discharge, discharge planning a reporting amongst teams across NES
Strengthen training with
colleagues to achieve
consistent approach.
Adopt consistent reporting
mechanisms across all site
including MH trusts
Quick Word approach – Social
worker face to face screening
on wards to assess situation
before referral – pilot at FGH
indicated reduction in referrals
and thus reduction in delays
through increased capacity in
team
March 2017 Reduced Length of Stay
Improvement against 4 hour target
Systems to Monitor Patient flow
Inconsistent across PAHT Sites, although Patient Tracker being piloted at Fairfield General Site.
standardised patient tracker
systems across all sites and
ideally the wider system
Ambulatory Care development
across all sites
Develop transitional pathway
March 2017 Improvement against 4 hour target
Reduced Data errors in reporting and wasted capacity resulting from this
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for patients to get out of acute
beds into community resource
(not rehab potential type
patients ie IMC) just ready to
go home but waiting in acute
beds
Acute – review of key policies
at PAHT including;
bed management,
site management and
escalation
Multi-Disciplinary Multi-Agency Discharge Teams (Including Voluntary and Community sector)
Co-location of health and
social care teams at
Rochdale Infirmary.
Variable levels of resource
between hospital site and
often impacted by varying
levels of demand at each
site.
Increased level of trust in
system between teams
regarding transfer of care
and social work and re-
ablement services
Voluntary and community
sector engage in integrated
capacity and demand analysis
of current state and future
state models
Enhance governance and
engagement of locality
meetings to engage wider
system and more robustly
mange SRG schemes
Single line management of
MDT discharge teams – in
progress through current
developments 1st June 2016
March 2017 1st June 2016
Improvement against 4 hour target
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care collaborative
Weekly operational group
meetings to monitor system
pressure and take remedial
action
Home First Discharge to Assess
Not very well established in
Rochdale Borough – the
nearest is STARS
Integrated Intermediate Tier of Services improving patient flow out of hospital in a timely manner
Develop transitional pathway
to enable discharge to assess
from acute site. Recent work
highlights need for this in our
locality
March 2017 Reduced Length of Stay
Reduced delays
Seven-Day Services
7 day services in place
across the system, although
not all 24 hours a day but
covered through extended
hours to 8pm
Integrated neighbourhood teams to go live in July 2016 to improve system wide support over 7 days and link into already extended integrated intermediate care offer
July 2016 Weekend discharges
Reduced delays at weekends
Trusted Assessors
Rapid Process for
Improvement work includes
project to develop Trusted
Assessor pilot with NES
Colleagues – currently
piloting on ROI site.
Resources still an issue to
Engage and support the development of this work to ensure our locality need is reflected in final definition of trusted assessor.
March 2017 Reduced delays
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deliver
Focus on Choice
Locally we have limited choice of provider in MH care market and high number of providers seeking financial top up to accept packages, which reduces choice for cohort of patients requiring residential nursing home care.
work with commissioners to develop market in order to reduce local challenges
March 2017 An increase in available providers in the market
Enhancing Health in Care homes
Nursing and GP teams
aligned to care home and all
have community matrons
linked
Quality and safeguarding –
Leg ulcer pathway in place
and nationally recognised as
reducing prevalence and
admissions resulting from
leg ulcers
Yellow Care Plans in place
for patients with long term
conditions to enable quick
understanding for
ambulance crews and
clinical teams on patient’s
status.
Carers night sitting service in development Partnership work to be developed with CAU at Rochdale infirmary to have timed visits for patients in a move to more managed care of conditions rather than reacting through Emergency Clinics A review of contracts for care
homes to include criteria to
accept weekend referrals
Review top up arrangements
with providers
Develop market as part of
integrated offer
March 2017 Reduction in admissions from care homes
Updated contracts to include weekend acceptance criteria
Reduced Length of Stay
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Explore possible shared care
management of staff with care
homes
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During 2016, an Analysis of the volume of patients with a Heywood Middleton and Rochdale
address declared medically fit for discharge (MFFD) across the 4 Pennine Acute Hospitals
sites was completed for a 4 week period.
Rochdale Health and Social Care system has experienced unprecedented pressures on
service demand since November 2014. This has resulted in a failure to achieve the
Emergency Access target of 95% for all patients to be seen, treated and discharged from
Accident and Emergency (A&E) within four hours, both across the country and within the
Pennine Acute footprint.
There is, however, a much larger group of patients who also occupy acute hospital beds and
are described as Medically Fit for Discharge (MFFD). It is thought that, across the Pennine
Acute footprint, there are up to 150 patients per day who are MFFD. What became clear
was that the sites across the Pennine Acute footprint do not have a consistent approach to
the recording of MFFD patients.
For example, The Royal Oldham Hospital only reported a very small number of MFFD
patients in the following three categories only:
1.1. CHC
1.2. Residential Care
1.3. Family Choice
MFFD cases are reported daily and the analysis completed was a midweek point of
Wednesday over four consecutive weeks from 27th January 2016 to 17th February 2016.
HMR Patients with an MFFD Status
The following graphs show the position across all for sites (FGH – Fairfield General Hospital,
ROH – Royal Oldham Hospital, NMGH – North Manchester General Hospital, RI – Rochdale
Infirmary), across a four week period. The final graph shows totals for all four sites for the
period.
27th January 2016:
0123456789
FGH
ROH
NMGH
RI
Trend
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3rd February 2016:
10th February 2016
17th February 2016
0
2
4
6
8
10
12
FGH
ROH
NMGH
RI
Trend
0
2
4
6
8
10
FGH
ROH
NMGH
RI
Trend
0
2
4
6
8
10
FGH
ROH
NMGH
RI
Trend
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Totals for the Four Week Period:
The breakdown was as
- Continuing Health Care Process (CHC) (38)
- Family Choice (18)
- Social Work Assessment (11)
- Residential Care (10)
- Occupational Therapy/Physiotherapy (10)
- Care Packages (9).
- MCA/Best Interest (10)
- Equipment (5)
- Mental Health Specialist Assessments (RAID Team) (3)
- Intermediate Care (3)
- Learning Disability Funding (1).
There is a co-ordinated effort to reduce the number of medically optimised patients waiting
for discharge across the 4 Pennine Acute Trust hospital sites. This work has been driven by
a rapid process for improvement programme of work which was initiated and supported by
the Trust Development Agency (TDA). This has executive agreement from all partners and
has already set ambitious targets. This work is a key priority during 2016/17 for the North
East Sector.
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10152025303540
FGH
ROH
NMGH
RI
TOTALS
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Scheme Level Spending Plan
2016/17 Schemes Summary Description Investment £000
Intermediate Tier Service
- Year 2
The ITS mobilised 1st September 2015. This was a lead provider collaborative model
commissioned on an outcomes based model.
£5,933,500
Re-ablement including
Telecare, Dementia and
Equipment
Co-produce with patients, service users, public and voluntary and community sector
improvements in self-care. Including care navigators, advanced assistive technology,
patient held records and the development of Dementia Friendly Communities.
£783,233
Carers
The Carers re-commissioning commenced in September 2015 with a patient
satisfaction survey. The findings have identified the top 5 areas of concern for Carers
and their families. This work will be modelled into the Carer’s service specification
2016/17 and procurement process due to be completed in summer 2016. This is
aligned to the ‘Living well with Dementia’ pathway redesign work that is also in
progress as part of the Rochdale Locality Plan.
Continue to develop carer specific support – including carers breaks.
£478,767
Disabled Facilities Grant Disabled Facilities Grant Equipment and adaptations are a key enabler to maintaining
independence we will work with Districts to consider future actions required in
delivering DFG.
£2,046,740
Implementation of the
Care Act
Carers assessments and support services; Safeguarding Adults Boards; and national
eligibility.
£637,000
Protecting Social Care
Services
Ensure existing services commissioned under 256 agreements are aligned to the
objectives of transforming integrated working and continue to protect social care.
£8,217,000
TOTAL £18,096,240
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National Metrics
Metrics Definitions
Permanent admissions to residential and care homes
Reduction in admissions based on rate of Effectiveness of reablement – those 65+ still at home 91 days after discharge.
Delayed transfers of care
Agreed 3% decrease on 14/15 baseline. This is still challenging
Emergency admissions 3.8% reduction. Aligned with CCG planning submission 17th March 2016.
Patient / service user experience
No of Carers who receive a service or information advice and guidance as a minimum per 100,000 population (aged 18+)
Local Metric
Now the ITS model is in its second quarter of delivery, this performance metric will be one of the outcome measures that is incentivised in the contract.