Wessex Academic Health Sciences Network
23 April 2015
Suzanne Wixey, Programme Director
Integrated Care and Support
My life a full life is a new way of working together towards building sustainable
health and social care on the Island
Collaboration between the Isle of Wight Council, Isle of Wight NHS Trust and the Isle
of Wight Clinical Commissioning Group, working in partnership with One Wight
Health, third sector, local people, families and carers
Catalyst for change, bringing together organisations to deliver a significant
programme of change
The focus is on person centred community responses to ensure people receive coordinated care and support
Anticipated Benefits
Benefits
 GP’s time freed up
 Support closer to
practices
 Greater co-ordination
Benefits
 Reduction in referrals
 Greater co-ordination
ensuring right agency
responds
 Reduction in admissions to
long term care
CCGs
Trust
IWC
Public
Benefits
 Less admissions to hospital
 Reduction in bureaucratic
systems
 Greater co-ordination of
care and support across the
organisation and within
communities
Benefits
 Improved outcomes
 Greater freedom and choice
 Empowered people
What we have delivered
• Developed a vision, with local people for the delivery of integrated care and
support which works well with people families and carers
• Focussed on prevention rather than cure, with health and social care focussing
on maintaining wellbeing in communities – before people need services
• Enhanced multi-agency planning and organisational collaboration across the
statutory, voluntary and private sector
• Improved access to local information and advice enabling people to make
informed choices about what support is available in local communities
• Made the most of local resources ensuring the development of the health and
social care system is sustainable in the longer term, pooling budgets, creating
integrated services, working in partnership with the voluntary sector and local
communities
What we have delivered
• Promoted self care and self management to the Island population
• Secured 5.6m to eradicate social isolation for older people
• Delivered a crisis response service for people on the Island, reducing
inappropriate demand on hospital and residential placements
• Developed integrated approaches on a locality basis, ensuring care and support
is delivered closer to home – working with GP’s primary care and multi agency
teams
• Developed an evaluation framework and integrated metrics approach to inform
future commissioning and development with a firm evidence base
Proposed MLAFL Evaluation Metrics
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Emergency readmissions within 30 days of discharge from hospital (PHOF 4.11)
Hip fractures (65-79 and 80+) (PHOF 4.14)
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s* (NHSOF 2.3.ii
Estimated diagnosis rate for people with dementia (PHOF 4.16, NHSOF 2.6i)
Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital
into rehabilitation/reablement services (ASCOF 2B, NHSOF 3.6i) (There has been a small change to the
definition of the measure, but 2011/12 data are broadly comparable with 2010/11 data)
Proportion of older people (65 and over) who were offered rehabilitation following discharge from acute
or community hospital (NHSOF 3.6ii)
Proportion of people who use services who have control over their daily life, to be revised from 2014
(ASCOF 1B). (Caution should be exercised when comparing the underlying 2011/12 data to 2010/11 data
due to changes in survey methodology).
Proportion of adults in contact with secondary mental health services living independently, with or
without support (PHOF 1.6, ASCOF 1H) (2011/12 data are not comparable with 2010/11 data, as 2011/12
data is based on the last quarter of the year).
Permanent admissions to residential; and nursing care homes, per 1,000 population (ASCOF 2A).
(2011/12 data are not comparable with 2010/11 data)
Delayed transfers of care from hospital, and those which are attributable to adult social care (ASCOF
2C). (A move from weekly to monthly data means that 2011/12 data are not comparable with 2010/11
data).
Overall satisfaction of people who use services with their care and support (ASCOF 3A) (Caution should
be exercised when comparing 2011/12 data to 2010/11 data due to changes in survey methodology).
Proportion of carers who report that they have been included or consulted in discussion about the
person they care for (ASCOF 3C) (Carers Survey biennial – no carers data for 2011/12).
Proposed Integrated evidence-base model
Inform Workstreams
towards “I” and “We”
statements
Health and Wellbeing
Board
MLAFL Programme
Board
MLAFL Evidence Base
Voluntary Sector
prospectus
funded projects
 Help and Care
Health Failure
Support Group
 Age UK Digital
Inclusion
 Age UK Care
Navigators
 Footprint Trust
Warmer Wight Plus
Integrated
Locality Teams
 Staff self-evaluation
journal
 Programme theory
 Monitoring data to
track project change in
relation to KPIs/CSFs
(“I” and “We”
statements)
 Plurality methodology
 Cost-benefit analysis
Self Care/Self
Management
Crisis Response
External research
and data
 University of Southampton – protocol for PLANS and Social Networking
study on the Isle of Wight
 Research Co-ordinator – focus groups, one-to-one interviews opened and
closed, questionnaires and other innovative and participatory tools with
staff, people, families and carers
 National data/evidence statistics – HES, GP National Patient Survey,
Reports/Journals
 Local data/evidence – Healthwatch, People Matter
 MLAFL Evaluation Metrics – ASCOF, PHOF, NHSOF
Vanguard
• In March 2015 the Isle of Wight was chosen as a national Vanguard
site
• One of 29 shortlisted from 269 who put forward their ideas for how
we want to redesign care and support
• Maximise the use of resources and avoid duplication and provide
better solutions to outdated provision
Vanguard
What we want to achieve?
• Develop local community leadership within new and existing services that
integrate and co-ordinate sustainable development opportunities and outcomes
• Develop leadership and workforce competencies to deliver truly integrated care
• Continue to build community capacity with public health and other key
stakeholders
• Embrace innovation that enhances the lives of individuals on the Island
• Nurture community strengths and adopt an asset based approaches to health
and wellbeing, care and support
• Improve the quality and effectiveness of support and services which will have a
real impact on people and communities
• Develop the next generation community- based models of health and well being
and enhance the lives of individuals, families and carers on the Island
• Use our newly acquired Vanguard status to lead on the development of
innovative game changing models
New Models of Care
Integrated Model of Care
Prevention and Early Intervention
Integrated Single point of access
Primary Care Lead Localities
Fully Integrated Acute provider
Added Value to improve outcomes and quality for individuals, whilst delivering cost efficiencies
Creating sustainable change across the
system as a whole, where it makes sense
and if needed.
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All Services for Health and Social Care to be
triaged through Single Point of Contact,
which includes all Organisations
Build on the development of working
together across Primary and Secondary
Care to ensure seamless transition of care
and support.
Innovative Commissioning new models of care
to achieve quality
Activated Patients
Helping people to live longer and more
healthy lives
Focusing on early intervention and
prevention.
Healthy workplaces
Research and Evaluation to measure
effectiveness and impact to contribute to
redesign of services and continually
meet local need.
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Rehabilitation & Reablement
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Crisis Response
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Hospital Telephony
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Community Nursing
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Wightcare Community Alarm Service
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Out of Hours
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Voluntary Sector
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Patient Transport
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Hospital Car Service
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Adult First Response
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Develop our own capacity and capability
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My Life Get Active
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Empower and involve Communities
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Pharmacy
Raising awareness of Health screening
programmes available and encouraging
participation
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Social Workers
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Telehealth
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Proactively targeting population using a Risk
Stratification programme
Achieving full traction of key priorities
across Primary and Secondary Care, for
example:
Expanding Leadership roles in primary care to
include a wide range of professionals e.g.
Health and Social Care, pharmacist, voluntary
sector etc.
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Moving towards Multispecialty Community
Providers for a wider range of care for
individuals
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Making fuller use of digital technology new
skills and roles.
Flexibility in working with Primary Care i.e.
Digital Consultation with Health and Care
Professionals (Consultants, Nurses, AHP,
in reaching into Nursing and Residential
Homes)
Promoting Self-care and Self-Management at
every opportunity to reduce demand linking into
the Voluntary Sector
7 day working developing expert generalist to
work a lot more intensively with individuals and
more accessible urgent care services
Using local intelligence to target specific
populations to provide better outcomes i.e.
quality of Health and Care for people,
impact on individual Health and Wellbeing
and System efficiencies
Development of Estate to deliver community
Integrated Health and Wellbeing centres
Building resilience with the third sector
(Nursing Residential Homes, Voluntary
Sector)
Developing sustainability of Primary and
Secondary Care across Health and Wellbeing
system as a whole.
Recruit through partnership Acute
specialist care to outreach into Community
Extended group practices to form either as
federations, networks or single organisations
Commissioning
Contracts capitated
IW Council
Finance
Cost Benefits
IW NHS Trust
Developing a Community currency
through a pathway costs
IW CCG
Voluntary Sector
Key Enablers
Integrated
Performance Metrics
Primary Care
Information
Technology
Speeding up flow through hospital
Reduced inappropriate Non-elective
Admissions
Reduced Re-admissions
Reducing Admissions to Nursing /
Residential Homes
Workforce
Nursing & Residential Homes
Quality
IW Prisons
Governance
IW Providers
Vanguard
• Working with KPMG creating a roadmap for the Isle of
Wight - MLAFL powered by Vanguard Programme
• Visit by New Models of Care Team 18/19th May
• Building a compelling story of the journey so far, where we
can accelerate progress and what help we need
• Learning from other sites
• Peer visits to other sites
• Excited and enthused about the future and the opportunity
Vanguard will bring to the Island
• Aspiring to be a national leader for integrated care
Delivering the Future
A shared vision for health and social care on
the Island
Contact details
Suzanne Wixey
Programme Director Integrated Care and Support
Room K, Innovation Centre
St. Cross Business Park
Newport
Isle of Wight
PO30 5BW
Email: [email protected]
Tel: 01983 822099 x 3045
Email: [email protected]
Web: www.mylifeafulllife.com