Name of presentation Improving health in Greenwich: Linking integrated health & social care with primary care

Name of presentation Good Engagement Good Design Great Outcomes! Our Plan…

Name of presentation Phase one of integrated care in Greenwich

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The Greenwich Integrated Care and Support Collaborative will provide proactive, efficient and effective care to a selected group of individuals with complex needs that is personally tailored for each individual and delivered by a highly functioning, motivated professional and lay team Our Vision and Main Aims: Phase 2 Our aim is to achieve the following by the end of: Year One Team Around the Person Effective working relationships and culture Infrastructure in place Tried and tested systems and processes Service users know who to contact re needs Year Three A significant reduction in hospital & residential care admissions; more early supported discharge and care outside hospital Systems and processes running smoothly High levels of client and staff satisfaction Improved wellbeing compared to controls

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Who will the GCC test and learn focus on? High Risk High Complexity General Practice Mental Health high risk patients Social care services users with complex problems Community services and DN case load ‘ Business as usual’ for most patients in General Practice High risk, high complexity patients. Many will be targeted in care planning DES/New Enhanced Service

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Engaging general practice Narrative that related to better patient care and better working lives Regular attendance by service lead at GP network meetings – identifying and responding to glitches Detailed planning and good communications Test and learn phase well resourced – easier to accommodate GP needs Making it easy to be involved with GCC

Name of presentation Sustaining and strengthening engagement Monthly action learning meetings Facilitation and support by critical friends Proving good outcomes Spread to other parts of the borough Effective integration requires careful ‘maintenance’

Name of presentation From a patient and carer perspective

Name of presentation Personal outcomes from GCCP involvement Individual ‘I statement(s)’ addressed Named professional to coordinate ongoing care Care plan agreed across multiple professionals with improved understanding of respective roles and responsibilities Additional services and activities from statutory / voluntary sector (may be long term or short term) Home environment adapted to meet personal needs Carer understanding of available services for service user Carers personal support needs addressed

Name of presentation How will we know if we have been successful? 1.Individual Experience 2. Staff Experience 3. Systems, Processes & Pathways 4. Strategic Objectives Year 1 Test and Learn e.g: 1 – Possible improvements in client satisfaction surveys & “I” statements compared to baseline 2 – Baseline staff satisfaction (+/-organisational culture) scores 3 – Number of integrated care plans and number of services being used by individuals 4 – Possible improvements in selected service utilisation data compared to a control group Year 3 e.g: 1 – Significant improvements in “I” Statements, client satisfaction and clinical/wellbeing scores 2 – Significant improvements in staff survey and organisational culture sore scores 3 – Pathways and protocols shared between participating organisations; 4 – Significant improvements in utilisation of services (emergency admissions, A&E attendance and GP visits) compared to control group 4 – Financial balance or better

Name of presentation The Partners