Improving Outcomes through Integrated Care

Dr Anne Hendry National Clinical Lead for Integrated CareJoint Improvement Team

What Matters to Me

> Coordination and continuity of care> Trusted relationships> Accessible information and advice > Good communication with, and between, staff

People living in more deprived areas in Scotland develop multimorbidity 10 years before those living in the most affluent areas

Mental health problems are strongly associated with the number of physical conditions, particularly in deprived areas in Scotland

Public Bodies (Joint Working)(Scotland) Act

• Bringing together the accountability of statutory partners in an equitable way, to deliver better outcomes for patients, service user and carers - all adults and all care groups.

2014 National Action Plan for Multiple Conditions

•Adults with multiple conditions are supported to live well and experience seamless care from the right person when they need it and where they want it.

•Scotland is a world leader in research, innovation and improvement for Multimorbidity and Integrated Care.

4 Primary Drivers 10 Local Actions on three levels:

• Individual - care planning and consultations that help people to have control over their conditions, care and support and to achieve their personal outcomes

• Local team - integrated care and support that builds on community assets and promotes independence, wellbeing and resilience

• Whole system - pathways that are designed around people with multiple conditions and to reduce health inequalities

5 National actions for Government and Special Boards to drive excellence

• Adaptive leadership • Research, innovation and improvement infrastructure

Technology Enabled Integrated Care

Intermediate Care

> Rapid Response / Early Supported Discharge

> Reablement> Hospital at Home> Step Up / Step Down

community beds

http://www.knowledge.scot.nhs.uk/chin

Residential Care Task Force

> Personalisation > Capacity Planning> Commissioning> Managing Risk > Fee Structure and Funding> Governance and Quality

> Pathfinder project lead by SCVO with East Dunbartonshire Voluntary Action, Community Health Partnership, Council and local third sector organisations.

> Working intensively with a number of third sector organisations to help evidence their impact on community well-being.

> Provides training (delivered by Evaluation Support Scotland) to help them identify their outcomes and produce the kind of evidence that will demonstrate their impact.

> www.scvo.org.uk/building-healthier-and-happier-communities

Local Partnerships with Third Sector

All Improvement is Local

> Locality as the Engine Room of Integration

> Where we will best engage and empower those that deliver and receive health and social care

> Where service changes can have a real and quick impact on outcomes

Intermediate Care

Care

Ho

mes

Community Assessment & Rehabilitation

Respite

Intensive Home Support

Very Sheltered Housing

Assistive Technology

Community Alarms

Home Support

Care Management

Community Health Services

Palliative Care

Continence/Falls Services

Ac

ute

Ho

sp

ital

Serv

ice

s

Community Pharmacy

Carers Support

Integrated Health & Social Care Services

Health Promotion

Sheltered Housing

Locality Link Officers

Activity Programmes

Voluntary Organisations and Supports

Supports & Services for Older People in North Lanarkshire

Building Trusting Relationships

> working seamlessly with colleagues in NHSScotland and partners who provide care

> making more and better use of technology and facilities to increase access to services

> strengthening workforce planning to ensure the right people, in the right numbers, are in the right place, at the right time

> putting new and extended roles into practice

Integrated Care Support Worker

9 Health & Wellbeing Outcomes (proposed)9 Health & Wellbeing Outcomes (proposed)

Integrating Care for and with Jessie