Anne Tidmarsh

9 July 2016 eHealth conference

Director Older People and Physical Disability

Kent County Council Lead director for Kent Integration Pioneers

Design and Learning Centre for Clinical and Social Innovation

Kent and Medway Integration Pioneers

ROOMforLIFE:

Innovative strategies for mobilising communities

• Integrating health, social care and the voluntary

sector to empower independent living

• To live and die safely at home – supported by

anticipatory integrated electronic care plans

• Mobilising the community - new models of support

• Covers the 1.5M citizens of Kent

• Includes all commissioners and providers of health

and social care, voluntary sector , including districts

(housing) and public health

Kent and Medway Integration Pioneers

Zeelandic Living Room concept fits with Kent’s vision :

Healthy independent older people through partnership

between business , health and care, the voluntary sector

and older people .

Learning from Zeeland through Biz4Age project ; results

same as what Kent would like to achieve : “Innovation lab

or space” where people determine what is important to

them.

Zeelandic Livingroom to Kent

Key question :

Would you be able to

bring the Zeelandic

Livingroom concept

across the North Sea

to Kent ?

Partnership Zeeland and Kent

Zeeland presented the project to a small

working group in Kent.

Further partners were invited to see how

this could be translated to Kent.

The concept grew and although in a different country with

different services, the partners in Kent were convinced

that this could work and fitted with what the Integration

Pioneers in Kent wanted to achieve.

Innovation Lab - “RoomforLife”

Kent’s project launched

Flats in a Kent Rehab Centre.

Managers who could envisage how the concept could work.

Enthusiasm from creative , technical , design partners, health

and care and the voluntary sector.

Practical start with the help from Zeeland.

EU funding through Biz4Age.

Part of the Design and Learning Centre

Innovation Lab - “RoomforLife”

ROOMforLIFE , small businesses and voluntary Sector

• New technological , equipment and design solutions

important for health and social care

• Citizens are able to try out these solutions and use them in a

home environment

• When tested commissioners are clearer about benefits for

individuals, health , housing and social care

• Supporting self management and our understanding of

community capacity building and active healthy ageing

• Businesses at the heart of health and social innovation

Mobilising the Community

Building Community Capacity

Community finding different solutions

to support its citizens

Integration Pioneers Design and Learning Centre

Care Navigators – Facts & Figures Community • Face to Face Contacts- 386 • Email/Telephone contacts- 1657 • Average monthly referrals back to KCC-95 • Average monthly referrals from KCC- 125 • Average monthly with no ongoing need- 167

Care Navigators – Facts & Figures #2 Hospitals • Face to face contacts per month -315 • Email/Telephone contacts-933 • Avg KCC referrals to KCC- 20 • Avg referrals with no ongoing support-31

Delivering Differently in Neighbourhoods

WYE

• 2282 residents in 1147 Households

• 208 (19%) of households fall under ‘Vintage

Value’ category

Of this 208:

• 36 are supported elders in specialised

accommodation including retirement homes

and complexes of small homes

• 172 are elderly singles of limited means renting

in developments of compact social homes

• In July 2015 there were 18 individuals who

were receiving LA care packages

• Unknown quantity funding their own care

• There are 175 council owned properties in Wye

including sheltered housing.

• 419 people living alone (18%)

Delivering Differently in Neighbourhoods

– Facts & Figures #2

• Our Place PMG registered as CIC

• 8 work streams continuing to develop

• Social Care Co-operative forming

• Community lunch event

• Bulletin and Questionnaire ready to go

• Baseline data collection underway

• Over 75’s project- Wye Surgery

What next for WYE

• Service user data

• Recruit volunteers

• Developing the PMG

• Identifying and applying for funding

• Sharing information about local services

Delivering Differently in Neighbourhoods_

Newington

• 5210 residents

• 14.5% are over 65

• 20 people are 90 or over.

• 51 people receiving an ongoing support

package.

• The total annual spend is over £168,000

Steering group with local residents, churches,

community organisations, NHS health training

and KCC.

Visioning events identified areas of focus:

a) Improving community connections, to facilitate

a culture of neighbourliness;

b) improving access to information and

communications

c) gaining access to more activities

Also want to develop a social co-operative.

Delivering Differently in Neighbourhoods

– Facts & Figures #2

Learning so far

• Challenging existing structures of

hierarchy

• Ensuring total inclusion of members

• Incorporating the work that has been

done/learning from work before into

the current projects

• Educating people on co-production

and empowering people to make

decisions about their care

• Establishing communication

channels/methods that are both

viable and cost effective

• Sharing data- obtaining data

Care Navigator Plus – Facts & Figures

Practice data

Undertook evaluation of patients with:

Repeat phone calls

Repeat visits

Repeat calls to OOH

At Downs Way practice, 21 patients were

identified who had between them over 600+

GP contacts between July 2014-May 2015.

The same group of patients between May –

September 2015 had 61 contacts

That’s a potential saving of an average of

£26,550k assuming a GP appointment cost

of £45 each (The 2013 ‘Units Health and Social Care report’ from the

Personal Social Services Research)

Care Navigator Plus – Facts & Figures #2

Reduction in Social Care

Evaluation of the 84 pts supported at Downs Way

between May-Sept 2015.

34 were referred to multiple community services

away from Social Care. Assuming these people

would otherwise have been referred on to Care

Managers and SC support it is estimated that

between them the saving would be between

£53k – £211k.

Further analysis needs to be carried out to

confirm the savings and estimate the cost

avoidance of reduced referrals into permanent

care.

Pilot Evaluation - contd

16

• A&E attendances

Evaluation of patients who had attended A&E 2 or more times between

December 2014 – September 2015

Dec14 Jan 15 Feb 15 Mar15 Apr 15 May15 June15 July 15 Aug15 Sept15

Downs

Way

61 78 63 72 47 61 29 10 17 14

The Meads 51 53 54 54 56 67 25 17 13 12

Multiple attendees Downs Way - 77% reduction since May 15 The Meads - 82% reduction since May 15

Pilot Evaluation - contd

17

Reduction in Social Care

• 33 records of home care provision in Isted Rise in 2014

reduced to 20 in 2015

• 22 records of home care provision in The Meads in 2014 to 8

in 2015.

KCC transformation programme will have supported some of this

therefore further analysis needs to be carried out to confirm the

savings and estimate the cost avoidance of reduced referrals

into permanent care.

Integrated Care Pilot – Facts & Figures

Living Well- Age UK Integrated care pilot

programme in Cornwall 2012 aims:

• Improved Health and wellbeing

• Cost reduction of whole system

Targeted wrap around support to at risk older

people

Develops a co-ordinated management plan,

helping people to build social networks and

become better connected to their community

• 23% improvement in self-reported wellbeing

• 30% reduction in non-elective admission cost

• 40% drop in acute admissions for people with

LTC

• 8% cost reduction in demand for adult social

care

Integrated Care Pilot – Facts & Figures #2 Went live operationally in Herne Bay, Faversham and rural Ashford in Nov 2015 Living well co-ordinators attached to surgeries Cohort of 500 identified to criteria GPs referred Letters sent to gain consent 101 people referred in December SKC now interested

Some Facts- National Picture

1m People with frailty

10m People have two

or more LTCs

0.35m At end of life

16m People have one

LTC

Kent Picture

Mosaic profile groups: the number of residents classified to groups F and N in Kent.

• F -Senior stability (Elderly people with assets who are enjoying a comfortable retirement= 159,731

• N – vintage value, elderly people reliant on support to meet financial or practical needs = 80,022

And…

People living longer but not always well

The larger the number of co-morbidities a person

has, the lower their quality of life

Social isolation/loneliness a risk

factor for mortality in over 75s

16/06/2016

• Wellbeing is about more than just medically or socially managing

• It’s about thriving not just surviving

• It’s an ethical, social and financial issue

• Shared decision-making is key

• We need to support people and communities to manage, feel in control

23

Why does it matter?

Where does this take us?

Take the learning to develop a role that:

• Helps people who need advice and support to self

manage their well-being and LTCs

• Encourages people to be ‘good neighbours’

• Supports local groups to run social activities

• Be the conduit between primary and community care

and the voluntary and community sector

• To support establishment of local community

networks

• Identify local need, service gaps and work with

commissions and providers through DLC.

Say ‘Getting the right advice to support me in managing my condition’

Community agent

role/social prescribing

Accessing flexible services across a range

of channels, giving people relevant and timely choices-Help move through the system: care co-

ordinator/navigator

Peer training & community activators

Design &

Learning Centre

Have a different conversations: ask a

different question - what matters to you/me today

Working with people, carers,

professionals and the community to

deliver high levels of engagement

Planning self-management solutions

to meet local needs

How we create Sustainable/supported communities?

IMPACT OUTCOME OUTPUT ACTIVITY GOAL

There are multiple services which have similar offers which do not

communicate or cooperate

There is a high demand for crisis driven services

Logic Model This project aims to integrate the similar community support services for older people currently commissioned by KCC , district councils and CCGs into an unified community based service. Care Navigators, x

hospital based and x GP based Care Navigators and x Community Agents. The include district 12 ‘Older People’ include over 65 year olds, disability? Illness? younger?

The logic model is spilt into 2 parts: focusing firstly on project scoping and secondly on the activities that the role/s will undertake.

There is a lack of awareness of existing alternative community

based options

Change in No. of:

GP visits Hospital admissions Social care referrals

Care packages Care placements

Referrals

The scope of the project is limited by the available budget

Define practical scope of the role

Identify alternative options

Identifying high risk individuals

Signpost high risk individuals to

alternative options

Create map of local services and

community assets

Identify points of contact for services

and community assets

Identify service capability gaps and

overlaps

Identify similar ‘care navigator’ roles which could be combined into a unified role

Identify opportunities to share resources and

processes

Develop alternative options to meet the

capability gaps

Support the growth of alternative options

Encourage a culture of planning for old age

A person / team specification with defined roles and

responsivities

# services actively supporting planning for old age

# high risk individuals identified # high risk individuals

signposted

# alternative options # of people accessing

alternative options # volunteers

# identified gaps met # identified overlaps

Local services and community asset map

# points of contact # new collaborations

Proportion of non statutory service users increases

# alternative options accessible to older people

across KCC

awareness of services and assets amongst health and social

care professionals

bureaucracy # of contacts

More people receive quality care at home avoiding unnecessary admissions to hospital

and care homes

Kent communities are resilient and provide

strong, safe environments

Those with long-term conditions are

supported to manage their conditions

through access to good

quality care and support

Save money

Increase in knowledge of

alternative options to KCC services

Reduction in duplication of roles

Amalgamation of budgets

Consistent approach across KCC

Adapting current CN’s JD

Incorporating best practice from the pilots

Develop a countywide network of Community agents

Key to Active Healthy Ageing and Health Social Care Transformation

GP

surgery

alignm

ent

The way forward

Kent and Medway Integration Pioneers

Design and Learning Centre for Clinical and Social Innovation

Thank you Anne.Tidmarsh@kent.gov.uk Designandlearningcentre@kent.gov.uk @kentpioneers#design&learningcentre