Outline What is the Whole Systems Integrated Care Programme? - - PowerPoint PPT Presentation

Outline

• What is the Whole Systems Integrated Care

Programme?

• Progress to date
• Next Steps

What is the Whole Systems Integrated Care Programme?

• Hounslow is part of the North West London

Whole Systems programme: 1 of 14 national pioneers (“Early Adopters”) for joined up care

• A vision to deliver better integrated care
• If we can get it right, we know it will transform

the daily lives of many of our residents

• Builds on what’s being achieved

A vision to deliver better integrated care

• Our vision for whole system integrated care

is based on what patients and carers tell us is most important to them:

• a seamless service to patients and carers
• delivering person-centred care.

• Joined up health and

social care

• Organise around

people’s needs not historic

• rganisational

structures

• There is one set of

records shared across organisations

• Multidisciplinary

home care teams

• Fewer people are

treated in hospital, and those that are leave sooner

• More specialist

support for management of people in the community

• More investment

in primary and community care

• Social care and

mental health needs considered holistically with physical health and care needs

• Less spending
• n acute hospital

based care Care is provided in the most appropriate setting Funding flows to where it is needed Care is coordinated around the individual

A vision to deliver better integrated care

Transforming people’s daily lives

What are our population groups?

• Adults 16-74 years with one or more long-term conditions

(47,687)

• Adults and elderly people with advanced organic brain

disorders (839)

• Adults 75+ with one or more long-term conditions (9,865)

Transforming people’s daily lives

• 285,500 patients registered with Hounslow CCG GPs.
• 24,000 patients registered to Hounslow GPs were

residents of Ealing, 8,500 were residents of Richmond, and 5,500 in other locations outside Hounslow (tot.38,000)

• The number of households has grown 13% since 2001.
• Population growth is expected to rise between 2012 and

2020 by 12%.

• The growth rate of elderly population (over 65s) will be

above 18% between 2012 and 2020.

• Physical disabilities - About 35,000 people

have a long term illness or disability. About 12,000 report they are in “bad or very bad”

• health. (2011 Census)
• Carers – 8% of the adult population provide

unpaid care in the borough and only about 1% of adults are receiving a carer’s allowance.

• Dementia now affects one in six of people over

80 and this will continue to grow.

• Diabetes - The recorded diabetes rate is

significantly higher (6.1%) compared to the national rate (5.8%). There are an estimated 5,000 undiagnosed cases of diabetes.

• Cardiovascular disease - emergency admission

rates for chronic heart disease are significantly higher than the national rates (237 in Hounslow, 198 in England)

• Falls - Every year around one in three over-65s

living in the community and one in two people

• ver 85 will have at least one fall.

Builds on what’s being achieved

• Hounslow commissioners and providers have

been developing an integrated care model since 2012 and now has in place strategies and programmes delivering integrated care to its residents.

Builds on what’s being achieved

• Strategies include…
• the Out of Hospital Delivery Strategy (May 2012)
• Hounslow CCG Integrated Commissioning Plan (September

2012)

• Integrated Care Organisation (Feasibility study February

2013; Final Business Case July 2013) (with the Council and Hounslow and Richmond Community Healthcare Trust);

• the London Borough of Hounslow’s Adult Social Care

‘Change and Deliver’ Adult Transformation Programme

• The Better Care Fund (BCF) Submission April 2014

(Hounslow CCG and the London Borough of Hounslow).

Builds on what’s being achieved

• Programmes include…
• Better Care Fund programme
• ICRS / CRS / Prevention
• Integrated Care Pilot – multi-disciplinary teams in GP

localities

• Locality Working – social workers, care navigators
• Prime Ministers Challenge Fund
• Partner programmes – eg Hounslow & Richmond

Community Healthcare services, the Ambulatory Emergency Care programme at WMUH etc

Progress to date

• Overview of the programme
• Delivering the Outline Business Case
• Expert Panel Review

Overview of the programme

Delivering the Outline Business Case

Delivering the Outline Business Case

Co-production: four co-design sessions

Who was there

• Patients and Carers biggest

group in all sessions

• Hounslow CCG
• Whole Systems Lay Advisor
• West Middlesex University

Hospital

• Borough of Hounslow
• Voluntary / social organisations
• GPs
• Hounslow & Richmond

Community Healthcare Trust

• West London Mental Health

Trust What we covered

Session 1

• What is Whole Systems
• Co-production
• Outcomes wanted by patients, carers and social/voluntary groups
• Carers Strategy
• Dementia Strategy

Session 2

• What is Whole Systems
• Co-production
• Outcomes wanted by all participants
• Developing the Model of Care:
• The Multi-Disciplinary Team
• Three case studies from the Better Care Fund

Session 3

• Developing the Model of Care:
• The Multi-Disciplinary Team
• Two case studies from the Integrated Care Pilot

Session 4

• Developing the Model of Care
• The Multi-Disciplinary Team
• Self empowerment
• Care coordination
• Care Planning
• Implementing Whole Systems

Delivering the Outline Business Case

Outcomes

• “Be as independent

and well as possible for as long as possible”

• Get a ‘seamless

service’ that delivers care around the person, not around different systems

• “Best clinical practice

for my condition”

• “One person I can

talk to, who helps coordinate care and who is accountable”

Delivering the Outline Business Case

Developing a Model of Care

Expert Panel Review – 12th June 2014

• Department of Health: Ed Scully (Deputy Director,

Integrate Care)

• Monitor: Catherine Pollard (Director of Pricing Strategy

and Integrated Care)

• NHS England: Ben Dyson (Director, Primary Care)
• National Association of Primary Care: James Kingsland

(President)

• Lay Partner: Angeleca Silversides (West London)
• Kaiser-Permanente: Hal Wolf, (Ex COO)
• McKinsey: Tim Ward (Principal)
• Chen Med: Craig Tanio (Chief Medical Officer)

Next Steps

• To deliver Whose Systems integrated care will

mean significant change across the whole of our current health and care provider landscape, and perhaps for voluntary and social organisations too.

• Whole Systems is the catalyst and enabler for

this change. We must take this opportunity. We are working to a Full Business Case that will describe in detail how this can be done.

Next Steps

How we will continue to implement

• Strong governance framework and partnerships: H&WBB, Joint Commissioning
• Turning the Integrated Care Pilot in the five GP localities into business as usual
• Support the capacity and capability of Practices (PMCF & access to General

Practice 8am-8pm (Mon-Fri) and 6hrs / day weekends)

• Using the Out of Hospital contract mechanism
• Underpin services available to patients existing Model of Care; co-design with

providers

• Progress and develop joint locality working and develop the role of care

coordinators

• Integrate work on Carers & Dementia, including dementia advisors at locality

level

• Timescales
• Contracts (incl. double running costs, TDA approval for Joint

Venture arrangements; providers )

• Getting people to work in a new way
• Enablers: IT and Estates (having the community infrastructure in

place)

• Scale and pace – but safe (particularly SaHF)
• Geography - impacts on Hounslow, Richmond and Ealing, e.g.,
• Patients registered to Hounslow GPs are residents of Ealing, Richmond and
• elsewhere. Also impacts e.g. on West Middlesex University Hospital
• Providers need to respond to their commissioners in all three Boroughs - would want

to see WSIC helping them manage this response

• Impacts on hospital social workers (eg discharge, patient flow with ICRS, variable by

borough)

Next Steps

“Wicked Problems”