Integrating Care in Eastern Cheshire

Community Based Co-ordinated Care Draft Outcome Based

Commissioning Specification

Wednesday 29th July 2015Fleur Blakeman and Bernadette Bailey

Integrating Care in Eastern Cheshire

Integrating Care in Eastern Cheshire

Integrating Care in Eastern Cheshire

Approach• Community Based Co-ordinated Care• Outcome Based Commissioning• Commissioning specification for transforming community care• Co-design with local people and care staff based on improving

the experience and effectiveness of care• Move from reactive to proactive care

– Personalised care that empowers people– Co-ordination and organisation of care over time– Continuity of care and the workers providing it– Care closer to home– Urgent response when required

Integrating Care in Eastern Cheshire

Risk Stratification

205, 561

60,038

99,508

997

8,973

29,924

Population

Very High Risk

(<0.5%)

High Risk (0.5-5%)

Moderate Risk (5-20%)

Low Risk (20-50%)

Very Low Risk (>50%)

Integrating Care in Eastern Cheshire

Key elements

• Community based care quality standards• Care model and care components• Key interventions, standards and outcomes• Integrated Community Teams• Short Term Assessment Integrated Response and

Recovery (STAIRRs)

Integrating Care in Eastern Cheshire

Enablers• Risk Stratification Tool• Cheshire Care Record• Single Point of Contact• Mobile technology• Assistive technology• Estates• Workforce• Organisational development and Structure• Leadership and cultural transformation

Integrating Care in Eastern Cheshire

Outcomes• People supported to live well at home• Increased numbers of people experience joined up

care• Less people have a health crises that results in

admission to hospital or care home• increased number of people re supported to live well

at home in times of crises• People are supported to maintain or return to

independent living in their own home

Integrating Care in Eastern Cheshire

Process

Commissioners• Specification• Commissioning Plan• Business Case• Contract

Providers• Operating Model• Financial modelling• Implementation Plan• Contract

Integrating Care in Eastern Cheshire

Provider Organisations Response• Operating Model – work in progress• STAIRRs – Single point of contact– Rapid assessment and care plan– Short term care

• Integrated Community Teams – Identifying people – Assessment and care planning– Care co-ordinator

Integrating Care in Eastern Cheshire

Proposed team structure• Six teams of co-located staff aligned to the peer group

structure• Supporting identified GP population

Chelford, Handforth, Alderley Edge and Wilmslow

Bollington, Disley & PoyntonKnutsfordCongleton & Holmes ChapelMacclesfield (x2)

Integrating Care in Eastern Cheshire

When?

Engagement and sign off

Integrated Teams and STAIRRs

start

Expand to all targeted groupsApprox. 20,000

people

July/August

2015

October 2015 April 2017April 2016

Integrated Community Teams

delivering proactive and reactive care