Parallel Session: Integration in Action
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The document discusses the evolution and implementation of integrated care services in Fife and surrounding areas, highlighting the Integrated Community Assessment and Support Service (ICASS) established in 2009, which aims to provide seamless home care and rehabilitation. It outlines the challenges faced in integrating different systems, the need for effective leadership and collaboration among partners, and the importance of adapting to changing circumstances while maintaining a clear vision. Additionally, it presents data on outcomes and emphasizes the desire to shift care balance towards supporting individuals at home rather than in residential settings.
Parallel Session: Integration in Action
- 1. Integration in Action Workshop Welcome – Angiolina Foster CBE Director, Health and Social Care Integration Scottish Government
- 2. Integration: yes really! Experience from Fife: Intermediate Care Fiona Mackenzie Fife Partnership Kirkcaldy and Levenmouth CHP
- 3. What were we doing? • Taking a wide range of services across the partnership that had been started over the years, and use them to reshape services in a fully integrated model. • We call this ICASS – Integrated Community Assessment and Support Service. • Started in 2009… still work in progress. • Overall aim to provide care at home wherever possible, in an easily accessible and fully integrated service model.
- 4. Integration – The Reality Required What we have Increasing activity Resources remain the same or reduced Easy to access Multiple access points Integrated design to suit personal outcomes and needs Separate systems designed to deliver individual organisations aims Able to respond quickly 5 day service, set up to suit providers Able to plan an anticipate needs of the most frail Reactive design with limited structured ACP/Care Manager roles Designed by users Designed by Services
- 5. Pt at Home Mixing Bowl Prevention of Admission Supporting App Early D/C IRT EHCT CRU HC Com Hospital Com Pharmacy Sport & Leisure Carers Trust Day Care Vol Org Carers CPN’s Physio Int Housing GP CRTCAST DN SW COT Transport Falls Response PT Care Needs Identified COMMUNITYHOSPITAL Crisis Anticipatory No SPOA KIRKCALDY & LEVENMOUTH – CURRENT MODEL IC 2009
- 6. Just when you have a plan.. • New services come on board - Change Fund . • Intermediate Care comes of age. • Increasingly clear that current model not sustainable = everyone has a view especially about the role of others. • Partners are responding to issues in own area e.g budget and emergency access pressures, Council contact centre • Other initiatives get to implementation point, and need to be joined up coherently.
- 7. H@H Case Management Assessment, Triage, Inreach to Acute Care, Managing Delays Home Care, Dementia and Frailty, Community Rehabilitation Case Management 35 Integrated Care Case Management 15 Access Point Administration 50 20
- 8. main actions • Model how we need to work – relationships always the priority • Leadership group established = one voice. • Access – review and recalculate how teams were working and where skill mix was needed to reduce admin and duplication of effort for staff • “Reach in” to acute care to improve decisions and hospital flow • Bring old teams together in new design = pain ++ • Ignore boundaries wherever possible
- 9. • Simplify language for those outside the system, its difficult enough on the inside. • Acknowledge future aims e.g have one access point for ICASS and home care. • Coordinate/ manage the care around the person – explicit role of case manager built in. • Embed and join up the new roles for people (and there carers) with Dementia and Frailty. Based on 8 pillar model - at last, systematic ACPs as integral part of ICASS.
- 10. the good stuff.. • Staff want to improve outcomes – it is what motivates them • When the vision is agreed and others start to see how it fits • Collocation of key staff gave immediate results despite the trauma of the move. • Use of White Boards and systematic processes eg regular board rounds involving all of team inc Home care. • Easier to get the right care for the situation using local knowledge and shared responsibility • If we say everyone matters – we need to act like it.
- 11. … and the tricky stuff • Systematic evaluation of complex and cultural change • When things come in left field e.g review of home care ( again), Hospital at Home introduction. • Data either difficult to collect or not currently available to support changes – IT systems unable to deliver at present. • Different T&C’s and line management accountabilities. Can be overcome but not in some critical areas eg. medicines in the community. • Still essentially 2 + systems involved in developing and delivering integrated model on the ground. • Would really like to do that but….
- 12. and so…. • Hold the Vision • Don’t be fooled into thinking there is a road map for this • Sharpen your compass reading skills • Always design intentionally • Get leaders together and build the relationships • Adapt to whatever comes along – but stick to the vision • “Involve” like your life depends on it – with every stakeholder • Get the data right
- 14. Please discuss the presentation you have heard and agree on: 1. The single biggest lesson you have learned? 2. One “Do”? 3. One “Don’t”?
- 15. Improving Outcomes Through Integrated Working Older Peoples Services NHS Forth Valley & Stirling Council
- 16. The Improvement Agenda Aim - Shift balance of care - Support more people to remain at home or return home - Reduce admission to hospital and improve delays to discharge - Avoid premature admission to care homes Embarked on whole system approach • Reablement • Rehabilitation at Home • Short Stay Assessment Beds
- 17. Outcomes Comparison 2009 2013 Care at home service users 1285 1403 Older people in care homes 670 472 Balance of Care 18% 35% Cost of care (care at home) £6.7m £6.7m Cost of care (Care Homes) £9.6m £7.3m
- 18. Integrated Structure Achievements and Wicked Issues • Staffing and Culture • Location/Assets • Procedures • Service user contracts and financial impacts • Evidencing impact for individuals
- 19. Moving Forward Stirling Care Village A Health and Social Care Partnership Residential (34) Mental Health Respite Palliative Health Beds (32) Intermediate Care / Rehab / respite (64) Comm Team Base Public and Day services “street”
- 20. Please discuss the presentation you have heard and agree on: 1. The single biggest lesson you have learned? 2. One “Do”? 3. One “Don’t”?
- 21. Integration in Action NHS Highland Jan Baird Director of Adult Care NHS Scotland Event 2013 - Collaborating for Quality
- 24. EBI ………. Evidence /Evaluation – attribution/ contribution challenges Managerial Reorganisatio n IT – access not integrated systems Evidence Base Quantu m
- 25. EXAMPLES OF HOW THIS IS MAKING A DIFFERENCE
- 26. EXAMPLES OF IMPACT SO FAR THE LONG AND WINDING ROAD BELFORD HOSPITAL INVERNEVIS CARE HOME
- 28. Please discuss the presentation you have heard and agree on: 1. The single biggest lesson you have learned? 2. One “Do”? 3. One “Don’t”?