Published on March 21, 2014
Altogether Better in West Cheshire Moving toward a whole-system, customer- centric approach to the delivery of health and social care Amanda Lonsdale – West Cheshire CCG Will Ivatt – Cheshire West and Chester Council
• Setting the scene • A West Cheshire perspective • The Ageing Well Programme • Moving toward a Whole System Approach • What is currently in scope • How it feels on the ground • How we measure success • Our challenges What does this presentation include?
A Contextual Glance A Whole-Place community Budget for West Cheshire The Ageing Well Programme Moving Toward a ‘Whole-System’ Approach Pan-Cheshire ‘Pioneers’
Why do we need to do this? A West Cheshire Perspective The Demographic Challenge • An additional 19,500 (26% rise) residents over the age of 65 • An additional 3,000 (41% rise) residents over the age of 85 1yr 2yrs 3yrs 4yrs 5yrs 6yrs 7yrs 8yrs 9yrs 10yrs What does this mean? • Locally we spend £133.6 million annually on health and social care for residents over 65 • The biggest areas of spend are long-term care (£28m) and non-elective in patients (£33m) • Point prevalence (2012)showed 25-30% of hospital occupants could be served elsewhere
The Ageing Well Programme Stronger Communities • Social Isolation, Keep Well Self-Care • Telecare, Telehealth, Extra Care Integrated Teams • 9 + 3 integrated community care teams, Single Front Door Funding and Contracting Model • New financial model based on Ageing Well Business Case
What are our current priorities? • Seeing the person as a whole – asking them what they want • Moving away from crisis management to prevention and the promotion of wellbeing • Carers - identification and support • A continued emphasis on joined up working across health, social care and other partners • A firm focus on commissioning effective, high quality services, rather than commissioning ‘time slots’
Integrated Communities Frailty Pathway West Cheshire Gateway End of Life Community Care Teams Dementia Single Referral Community Equipment MDTs Community Equipment Health & Social Care End of Life Third Sector Navigators Falls Holistic Patient View Urgent Care Telecare / Telehealth Intermediate Care Self Care / Stronger Comm Hospital @ Home 3d Sector Assembly Transitional Beds Residential Homes Enablers Funding & Contracting Patient Engagement Information Technology Workforce Development Accountable Care Org Shared Record Training & Education Block/Rolling Contract Risk Stratification HR/OD Aligned Budget Information Governance Pooled Budget Assets Estates FInance 5 Year Vision Pan- Cheshire Pioneer What’s in scope?
Integrated Teams – A Service Model
Frailty Pathway Tier 5 End of Life care Tier 4 More serious exacerbations Care needs more complex Tier 3 Enduring complex problem Care mostly managed in the community but requires specialised input Tier 2 Established long term condition or problem managed in the community setting Tier 1 Development of symptoms Tier 0 Well Care Approaches Care Settings Tier 5 – CGA and Palliative Care Tier 3 and 4 – Comprehensive Geriatric Assessment (GCA), Anticipatory Care Planning and Care Management Proactive integrated team based multi-disciplinary assessment, rehabilitation, telehealth, support and monitoring Tier 2 – Assessment, Care Planning, Support and Review Care co-ordination, support, rehabilitation, telehealth and carer support Tier 0 and 1 – Self Management Information, advice and support to self-manage Tier 5 – At home. Care Home, Hospice or Community Hospital Tier 4 – Acute Hospital, Care Home or at home with telehealth advice and support from specialist team Tier 3 – Community Hospital, Intermediate Care Setting or at home with advice and support from specialist team Tier 2 – Community Team and Rehab services Tier 0 and 1 – GP Practice, Pharmacy, Voluntary and Community Sector, Home, Web
“My care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes” (Source: service user perspective from ‘National voices’) (Source: Kings Fund) How do we measure success?
• Pick a deadline and stick to it! • Put people at the heart • Integrate where it makes sense • Avoid new silos • Get the ‘governance’ right • Be flexible on geography and client group • Manage expectations • Money talks • Maintain momentum Lessons learnt (& challenges to address)
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