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@jitscotland www.jitscotland.org.uk
JIT is a strategic improvement partnership between the Scottish Government,
NHSScotland, COSLA and the Third, Independent and Housing Sectors
Dr Anne Hendry
National Clinical Lead for Integrated Care
Working Together To Improve Outcomes
for Older People: Reshaping Care in Scotland
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
Demographic change for population aged 65+ Scotland
Potential impact on emergency bed numbers 2007-2031
0
2000
4000
6000
8000
10000
12000
14000
16000
Y/E Mar 2007 Projected
2011
Projected
2016
Projected
2021
Projected
2026
Projected
2031
Year
Bed
s
9%24%
41%61%
84%
Calendar year ’07 estimate
P Knight Scottish Government
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
2020 Vision for Quality
3
Everyone is able to live longer healthier lives at home or in a homely setting.
• Integrated health and social care, with a focus on prevention,
anticipatory care and supported self management.
• Care will be provided to the highest standards of quality and
safety, with the person at the centre of all decisions.
• When hospital treatment is required, and cannot be provided
in a community setting, day case treatment will be the norm.
• There will be a focus on ensuring that people get back to their
home or community as soon as appropriate, with minimal risk
of readmission.
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 4
Reshaping Care for Older People
• 10 Year Programme to 2021
• £ 300 million Change Fund 2011-15
• 32 voluntary partnerships between NHS: primary, acute, mental healthLA: social care & housingThird and Independent sectorsOlder people and carers
• Change Plans signed off by all partners
• 20% of funding to be invested in direct or indirect support for carers
Reshaping Care Pathway
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
Improvement Network
6
Cross sector collaborative to support innovation and test and spread actions which collectively improve outcomes
WebEx virtual meetings and e-bulletins
Communities of Practice and themed learning events
Online portal to share good practice, evidence and resources
Training in improvement , spread and sustainability
Use of measurement for improvement and benchmarking
Support to adopt assets and outcomes based approaches
Learning from the experience of people who use services
Coaching / mentoring to build local capacity and capability
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
Collaboration with Third Sector
7
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 8
Building
Community Capacity
Peer support and web based information and advice
to help people manage their conditions
Technology Enabled Local Integrated Networks of Care and Support
SPARRA Risk Prediction Tool
Outpatient
(1 year)
Emergency Department
(1 year)
Prescribing
(1 year)
Outcome Year
(1 year)
OUTCOME PERIOD
Hospitalisation
(3 years)
PRE-PREDICTION PERIOD
Psychiatric Admission
(3 years)
Any recent admissions to
a psychiatric unit ?
Any A&E
attendances in
the past year?
What type of
outpatient
appointments did
the patient have?
Any prescriptions for e.g.
dementia drugs? Or
substance dependence?
How many outpatient
appointments?What age is the patient?
How many previous
emergency admissions
has the patient had?
How many
prescriptions?
Any previous admissions
for a long term condition
(such as epilepsy?
Key Information Summary
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
Increased Adoption of Anticipatory
Care Planning – data from Forth Valley
14
7263
7652
8584
9144
9880
10706
11407
0
2000
4000
6000
8000
10000
12000NHS Forth Valley KIS/EPC Uploads
2013/14
2014/15
KIS Access : Dec 2015
Falls prevention and urgent response
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Apr
12
Ma
y…
Jun 1
2
Jul 12
Aug…
Sep…
Oct
12
No
v…
De
c…
Jan 1
3
Feb
13
Ma
r 13
Apr
13
Ma
y…
Jun 1
3
Jul 13
Aug…
Sep…
Oct
13
No
v…
De
c…
Jan 1
4
Fe
b 1
4
Ma
r 14
Apr
14
Ma
y…
Jun 1
4
Jul 14
Aug…
Sep…
Oct
14
No
v…
De
c…
Jan 1
5
Feb
15
Ma
r 15
Non injured falls in the Elderly - Conveyance Scotland 2012 - 2014
Community Hospitals and Intermediate Care Community of Practice
Supported at Home
76% are managed in
their own home
instead of Hospital
by the ASSET team
2,864
Patients accepted by ASSET in 29 Months
5.6 / Day
5.7 daysLength of Stay
76%
Beds Closed50
Value £2Million+
North Lanarkshire
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
0
10
20
30
40
50
60
70
80
90
100
No
of
Pat
ien
ts B
reac
hin
g 7
2 H
ou
rs
Week Commencing - Monday
Glasgow City Total
North East
North West
South
Linear (Glasgow City Total)
Number of older people whose discharge is delayed over 72 hr
by Sector, Glasgow HSCP
39% CHANGE FUND
SPEND 2014/15
SUPPORTED
CARERS
2.5
MillionMORE DAYS
IN OWN HOME
THAN ‘EXPECTED’
17%FEWER
OLDER PEOPLE
CONVEYED
to HOSPITAL
after a fall
(non-injured)
10%
REDUCTION
IN RATE OF 75+
EMERGENCY BEDDAYS
OVER 5 YEARS
1250PER DAY
FEWER PEOPLE
AGED 65+ IN HOSPITAL
BEDS
THAN ‘EXPECTED’
IN RECEIPT OF
FORMAL CARE AT
HOME
HAVE TELECARE
5500
PER DAY
FEWER PEOPLE
IN CARE HOMES
THAN ‘EXPECTED’
19%
FEWER
PEOPLE DELAYED
IN HOSPITAL
OVER 2 WEEKS
Integrated Resources - Minimum to be delegated
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Ex
pe
nd
iure
(£
m)
Hospital Community Health Family Health Services & Prescribing Social work
Scotland total
=£12.3bn
Minimum to be delegated
to Integration Authorities
=£7bn
Local integrated networks of care and support
http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-
Integration
http://www.jitscotland.org.uk/resource/reshaping-care-for-older-
people-change-fund-building-on-progress-june-2015/
www.jitscotland.org @jitscotland
24JIT is a strategic improvement partnership between the Scottish Government, NHS Scotland, CoSLA, the
Third Sector, the Independent Sector and the Housing Sector
