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Health and Care Innovation Expo 2014, Pop-up University S160 - Day 2 - 1545 - Learning from Cheshire West and Chester's Altogether Better Programme Amanda Lonsdale Will Ivett #Expo14NHS
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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 CCGWill 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 4More serious exacerbations
Care needs more complex
Tier 3Enduring complex problemCare mostly managed in the
community but requires specialised input
Tier 2Established long term condition or
problem managed in the community setting
Tier 1Development of symptoms
Tier 0Well
Care Approaches Care Settings
Tier 5 – CGA and Palliative Care
Tier 3 and 4 – Comprehensive Geriatric Assessment (GCA), Anticipatory Care Planning and Care ManagementProactive integrated team based multi-disciplinary assessment, rehabilitation, telehealth, support and monitoring
Tier 2 – Assessment, Care Planning, Support and ReviewCare co-ordination, support, rehabilitation, telehealth and carer support
Tier 0 and 1 – Self ManagementInformation, adviceand 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)