PowerPoint Presentation

@eoeleadership #eoeleadimp

Mid Essex Care Collaborative:

Brid Boraks

Karen Brazier

Andrew Brown

Alison Connolly

Kristina Galatiltyte

Kerry Hooper

Ros Wilson

The Team:

Alison Connolly

Andrew Brown

Brid Boraks

Karen Brazier

Kerry Hooper

Kristina Galatiltyte

Ros Wilson

Mid Essex Collaborative

Bringing personalised care closer to home for older people

As you will have seen from the initial booklet, our project idea was to .

During our residential course we realised that in order to be here today and be able to tell you about our success, we needed to narrow down our project.

Our initial session (certainly for us) provided most of our learning about how teams work and the issues to be overcome agreeing our new more narrowly defined project plan.

After lots of discussion we narrowed down the potential areas where we could make the most impact. Thats how we arrived at post-Stroke care. The organisations represented within in the room all had involvement in the care of Stroke patients and we quickly realised that this was an area we could make a positive impact on.

Leading to optimised person-centred outcomes for stroke survivors and their carers.

Explain how we moved from frailty to stroke.

Formed/stormed/normed aligned our shared values

Carried out research with existing services including stroke association

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Life after Stroke

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Frightened

agitated

vulnerable

angry

unsettled

worried

bewildered

thrown off balance

in pain

Unable to talk

Kristina see Kerry for a format

Audio runs 20-30 seconds and concludes with 4 main clear

Key messages coming through:

Why am I repeating myself

No one is talking to each other

What happens to me now

I dont know how to help my partner

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Why am I repeating myself?

No one is talking to each other?

What happens to me now?

I dont know how to help my partner?

Kristina see Kerry for a format

Audio runs 20-30 seconds and concludes with 4 main clear

Key messages coming through:

Why am I repeating myself

No one is talking to each other

What happens to me now

I dont know how to help my partner

6

What we set out to achieve - Optimising person centred outcomes for stroke survivors and their carers

Project Aims:

Empower stroke survivors, their families and their networks to help themselves

Wrap health, social ,voluntary and their personal communities around them

Adopt a holistic, targeted, coordinated and integrated approach to their recovery and maximise their independence.

Objectives

To provide support for all Mid Essex stroke survivors and their carers

To work in an integrated way across the stroke pathway with all providers of health and social care

To enhance the individuals understanding of stroke and its impact

To maximise independent living for stroke survivors and their carers/family

To support working age stroke survivors to return to work

To enable carers to be confident in their role

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Personal Learning

Greater awareness

Stay with difficult conversations

Not being prescriptive

Maximizing talent

Greater personal awareness

Awareness of how each of us likes to think (detail vs big picture) . To be aware that we need the creativity and energy as much as the process and detail.

Scratching the service using questions to understand the other persons view.

Enabling people to speak up and empowering people to help themselves / equality of voice

Listen, challenge and stay with difficult conversations

Expect conflict its is not a failure of process but a normal reaction and in fact can lead to greater engagement and potentially better outcomes.

Very practical example on our project the what we were doing took us a long time and much wine! But key was allowing enough time to drill into issues/topics/feelings to allow a true sense of clarity.

Staying with difficult conversations Roz

Staying engaged Brid too easy to disengage. Aware that this can happen and adopting strategies

Ability to flex ourselves and the project (Not being prescriptive),

For me this was the penny dropping on the social care input and people helping themselves not having a prescriptive pathway driven / one size fits all solution whereby they get what they are due.

Maximizing talent generosity of knowledge/ sometimes just do it

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How things were

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Stroke Inpatient

(Mid Essex Hospital)

Early Supported Discharge

(Provide CIC)

Generic rebab services

(Provide CIC)

Primary Care

Social Services

(Essex County Council)

Stroke Association

Stroke Psychology

(NEPFT)

OoA acute providers

Stroke Rehab Beds

(Provide CIC)

Speaking outline:

- Deliberately messy shows how fragmented

- Different providers with separate contracts and distinct requirements

- Different commissioners/partners with potentially different objectives

- Not necessarily lending itself to joined up working

- Not clear what core offer should be at each stage, e.g. six month reviews, stroke assoc input or when/where ECC are involved

- Nonsensical exclusions, e.g. stroke psychology represents how services were bolted on or piloted

- Overlap of requirements e.g. patient assessment forms

- Inadvertently failing to see pt as a whole

- Confusing for health professionals, let alone patients!

Not blame, as all working for the best intentions and evolved as reflection of environment at the time, but ILC gave us an opportunity to change..

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What we have achieved so far

Greater understanding

Effective partnership relationships

Redesigned pathways

Joint development and implementation of Life after Stroke specification

Stroke Association contract transferred from CCG to community provider

Dedicated Stroke Social Worker.

Kerry, do we want pics on here or happy with narrative? As we have the pic type slide on the earlier one, Ive gone for narrative with a bit of interest with pics, but feel free to change

Speaking outline

To follow slide unless ditch narrative

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Next steps

Consistent core offer

Integrated collaborative partnership work

Continue to push forward project within existing workstreams

Continue to work on Stroke Psychology

Implement Lead Provider across community pathway

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Thank you

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