Integration

Working together for a caring, healthier, safer Edinburgh

18th June 2012

Welcome

Ricky HendersonConvenor of Health, Wellbeing and Housing

Committee City of Edinburgh Council

What will the Edinburgh Health and Social Care Partnership deliver for

individuals?

Tim DavisonChief Executive – NHS Lothian

Sue BruceChief Executive – City of Edinburgh Council

• ‘public bodies are required to cooperate not simply for their own administrative convenience but with a view to the changing needs of the populations, whose health and social care needs are not experienced in isolation or in relation to the professional / organisational boundaries that currently exist.’

– Public Bodies (Joint Working) Bill.

• So what will we now be able to do for our patients and service users?

Integration

Professionals talk to each other

Professionals talk to her and her

carers

Good care suited to her needs

Control and Independence

To tell her story once

Quick safe responsive services

•Listen to Mrs Stewart and her Family•Better predict her needs•Are clear about the outcomes that Mrs Stewart wants and needs•Intervene rapidly to provide health care and care at home for her•Can support her to find mechanisms to improve her self-care in the community•Can support her carer(s)•If hospital treatment is considered necessary, can undertake assessment quickly and effectively•Can admit, treat and discharge her effectively into an appropriate place•Provide the best care, whatever the setting and we do this locally wherever possible

Mrs Stewart wants…

– Integrated local outcomes and strategic direction– Integrated governance and management

arrangements, decision making and accountability– Transparent resources ……..aligned and pooled

budgets– Integrated HR & Finance support and reporting– Integrated service planning and commissioning – Shared information and ICT - a joint view of our

patients/services users, sight of each other and the tools we need to do our jobs

In order to do this we need:

Challenges

‘Addressing these challenges will demand commitment, innovation, stamina and collaboration from all of us who are involved, in different ways, in planning, managing, delivering, using and supporting health and social care services’

Public Bodies (Joint Working( (Scotland) Bill.

Where are we now?

Public Bodies (Joint Working) Bill

• ‘Integration Authority’ between Health Board and Council responsible for delivering national outcomes

• Must choose one model of integration• Must delegate services, responsibilities and resources/budgets• Must have approved an Integration Plan- of how the Integration

Authority will be established and resources delegated• Requires 3 yearly Strategic Plan • Requires the Integration Authority to work with professionals,

service users, patients third and independent sectors, • Requires the establishment of a ‘consultation group’ to assist in the

preparation of the Strategic Plan.

Our approach so far….

• Health and Social Care Partnership– 50/50 partnership - Council / Health Board established– Will become formal decision making body of both

health board and council– Political representation agreed– Representation from clinicians/professionals, service

users, trade unions/staff partnership and third sector agreed

– Engagement with GPS and independent sector– Agreed Strategic Framework (Plan)

1Need and

dependency on formal services

are reduced

Strategic Outcomes:

2Care and support is

personalised and person-

centred

3Edinburgh’s carers are

supported to continue in their

caring role

4People are

supported and cared for at home

or in the most appropriate

setting

5Communities are

inclusive and supportive

6People and

communities are safe and protected

Strategic Vision

Working together for a caring, healthier, safer Edinburgh

Draft Edinburgh Health and Social Care Partnership Strategic Framework

PledgeHealth and wellbeing are improved in Edinburgh and there is a high quality of care and protection for those who

need it

Strategic Framework

Ongoing enabling work…

• Finance – aligned budgets for 2013/14– Aligned budget setting process

• HR – reviewing policies and procedures– Preparing organisational development plan– Aligning activity on values

• ICT – First priority – roll out of CareFX portal– Established joint group CEC / NHS

Comments from last session & progress update

Peter GabbitasDirector Health and Social Care

Mrs Stewart

Professionals talk to each other

Professionals talk to her and her

carers

Good care suited to her needs

Control and Independence

To tell her story once

Quick safe responsive services

Feedback

• Not starting from scratch

• Joint working for 10 years

• As a result we have….– Much trust and respect….– Much common understanding….– Many positive behaviours….– Much to be proud of …..

• Unscheduled Care Planning • Step up/Down Transitional Beds Projects (Care Homes,

Elizabeth McGinnis Court and Findlay House)• Community Therapy Services

– Integrated intermediate Care service– Edinburgh Community Stroke Services– Domiciliary Physiotherapy Service – Dietetics– Speech and language therapy service changes– Hospital In-reach

• Falls pathway review• Development of District Nursing Services• New Models of Care for Orthapaedic patients – further

development • Stroke Rehabilitation Pathways management review• COMPASS (Comprehensive Assessment for frail older people)• IMPACT Team• Telecare extension• Telehealth • In reach service – north and south teams• Willow project • COPD and diabetes pathways redesigned into more self

management / personalised• Intensive Home Treatment Team• Community Rehabilitation team (REAS) with joint approach to

Care Coordinators / Care Managers• Prepare (Children’s Services)• Edinburgh joint mental health planning forum• Lothian joint mental health and wellbeing programme board• Review of mental health pathways in the community• Links between Criminal Justice Service and Forensic Medical

• Care Worker Sector based Academy• Edinburgh Behaviour Support Service (dementia)• Medication Review and procedures• Expansion of equipment and adaptations and equipment D/C

pathway and online ordering• Community Connecting project/contracts• Carer Support Hospital Discharge Service• Community Transport• Inter-Agency portal• Lanfine Re-design• The Access Point – for chronic homelessness

(medical/housing and social needs)• The Access Practice• DALLAS• Hubs model for walk in centres (e.g. Leith/Craigmiller)• Directory of Services for GPs• Seven day working for some staff groups• Joint commissioning- for older people, learning disabilities

services, mental health services will be key• Joint Accommodation panels • Joint case conferences• Drug Testing and Treatment Order (DTTO) Team – already

working together well• Management of high risk sexual and violent offenders• Examiner Service• Joint assessment and care management meetings (The

partnership meeting)• Review of rehabilitation ‘Wayfinder’ • Local area coordinators - case workers for PD, LD and

Autism• Advanced recovery from surgery pilot• Strong links between health policy and public health • Poverty and inequality Theme Group• Standing group on Health inequality

Challenges – the bar is raised

• Demographics

• Complexity of need

• Financial austerity

• Expectations increasing

Future opportunities

• Joint vision and performance management framework• Joint information and ICT• Joint Risk Management• New preventative / supporting independence measures• New / streamline / change pathways of care• Single point of contact• Care Coordination• Multi-disciplinary Teams

Outline of service:

Substance Misuse

Colin Beck Senior Mgr Mental Health, Criminal Justice and

Substance Misuse - CEC

Iain BurnsInterim Service Manager

NHS Lothian Substance Misuse Directoratehttp://www.edinburgh.gov.uk/directory/124/drug_and_alcohol_services

Substance Misuse Services DTTO

an example of Integration

• DTTO (Drug Treatment and Testing Orders Service)

• Started in 2002

• Butler Trust Award 2010

Introduction

Revolving door

• Psycho social

• Medical

• Judicial

A balanced response

Team structure

• 30 years old

• 30 + previous convictions

• 10 periods of imprisonment

• 4 kids

• New partner who is pregnant

Stan

• 18th month contract

• allocated a dedicated DTTO team

• avoid imprisonment

• reports back to court on a tapering basis

• groupwork

What’s in it for me says Stan?

Dedicated Treatment Team

• Reduced re-offending

• Voluntary work and employability pathway

• Continued support and after care

Outcomes

South East Recovery Hub - A Model of Integration

The Planning / Set-Up

• Kaizen event

• We strive to offer the right service at the right time to support your recovery journey.

Key features• Co-location

• Jointly staffed drop-ins

• Joint triage and case allocation process

• Joint case meetings

• Operating instructions cover the whole process

Allocation Algorithm

Triage assessment

Information only Information provided Open door

Support for Adult Carers

?

Ongoing support

Counselling (Alcohol)

Counselling (Drugs)

Drug problem

Alcohol problem

Non dependent / other pattern of use

Dependant

ART

Counselling

Psychosocial

ELCA

Castle

Other dependency / pattern of use

Opiate / Benzo Dependant

CDPS

Psychosocial

1° stimulant

Counselling

CREW

Simpson House

Refer to whiteboar

d for capacity

Refer to whiteboar

d for capacity

Castle

Intensive Case Management

DRT

APS

Intensive Case Management

Mental Health

IHTT/MHAS

CPN/Psychiatrist

Mental Health IHTT/MHAS

CPN/Psychiatrist

Children involved

Use GIRFEC / Orange Book to

identify next steps

Child Protection

Concerns but not child protection

Support for family

Ongoing support for child

Rehab

LEAP

Bethany

3RT

CREW

VOCAL

ELCA

Simpson House

C&F Social Work

Aberlour/Circle

Follow GIRFEC / Orange Book

Sunflower Garden / Edin Young Carers

Challenges

• One drop-in for all of the South East of the city

• Demand on clinical services remains high

• Need to focus on post-stabilisation

Personalisation and person centred health and care

How will integration help us to deliver person centred and personalised health

and care which will achieve the best outcomes for individuals?

Personalisation and person centred health and care

Joyce SurfleetSenior Nurse Compassionate Care, NHS Lothian

Wendy DaleStrategic Commissioning Manager, City of

Edinburgh Council

How will integration help us to deliver person centred and

personalised health and care which will achieve the best outcomes for individuals?

What could it mean in practice?

What are we doing now?• Edinburgh Personalisation Programme

Board

• Lothian Person-centred Health and Care Reference Group

• Edinburgh Personal Outcomes Partnership

How will we know when we get there?• Person-centred care is seen as

everyone’s business

• Person-centred approaches are embedded across health and social care

• Services are delivered in active, collaborative partnership with people

• Person-centred values and behaviours are modelled by leaders at all levels

A personal perspective

Suselle Boffey

Tea & Coffee break

Group session

What opportunities does integration offer to provide personalised and person centred support to the

Stewart Family?

Next Steps

• To progress improvements in outcomes for people and to build on all the feedback so far;– Work stream for each of the main service area groups– Two senior officers (health and social care)– Focus on service improvement and effective use of resources– Remits to be developed incl.

• Compliance with policy direction and strategic outcomes• Stakeholder involvement and resource considerations