Our improvement offer to those providing care and support to people at home 12 May 2017 Thomas - Introduction

Look at some of the work the ihub does under the following themes: Plan for the session Overview of iHub Look at some of the work the ihub does under the following themes: Conversations Different models of care Strategic commissioning Your thoughts and questions Thomas – Outlines what session will cover

A national improvement resource for Health and Social Care Partnerships and NHS boards Thomas – Overview of iHub

Support health and social care partnerships help older people and people with complex needs to live well at home or a homely setting. Thomas to give overview on LWIC team, but mentioning relevance of other programmes/portfolio work.

We work with health and social are partnerships to… Developing a better understanding of local health and social care systems to find opportunities for improvement. Identifying people who could benefit from preventative support before they have a crisis. Increasing the uptake and quality of meaning anticipatory care planning conversations. Designing and testing approaches to delivering community-based preventative support to help people live well at home. Thomas Developing the workforce to deliver community-based preventative support.

Conversations Nathan Importance of enabling staff providing care and support to have good conversations and build relationships that allow discussions on important and sensitive issues.

Margaret’s experience Jean’s Pathway 1. Total cost including GP prescribing £ 18,000 Pathway illustration Admission 1. 32 days Admission 2. 16 days Admission 3. 3 days Care Home 39 days Outpatient Clinic Moved to care home for 39 days Social Care Assessment Death in hospital Hospital admission for 16 days Hospital admission for 3 days Hospital admission for 32 days Jean’s experience July August September October November December May June July August September October Care package provided Margaret’s experience Hospital admission for 4 days Social Care assessment Moved to care home for 73 days Death in Care home Nathan Purpose: To illustrate that person-centred, anticipatory care planning can make a difference in people’s experience of care. Narrative: Please meet Margaret and Jean. Two people with similar backgrounds and medical conditions but difference experiences of care in later life. Margaret had an anticipatory care plan to outline her wishes for her future care before she experienced her first hospital admission. Jean did not. Jean did not have a anticipatory care planning conversation before she was admitted to hospital. Acute services didn’t know what was normal for Jean or what she wanted for her care. This resulted in longer, multiple hospital admissions and she died in hospital, instead of in a homely setting. Margaret’s anticipatory care plan was shared with acute services via the electronic key information summary. This help acute staff understand what was normal for Margaret, her wishes for her care and the outcomes she wants to achieve in life. This helped her get home quicker and get the care she wanted. This demonstrates an opportunity to improve quality of care, which reduces the demand on services (52 bed days vs 4 bed days) and is more cost effective (£18,000 vs £7,100). Admission 1. 4 days Care home 73 days Margaret’s Pathway 2. Total costs including GP prescribing £7, 100 Data provided by Information Services Division at NHS National Support Services

Search for Jack’s story ACP Nathan

Nathan

Nathan Also mention palliative care work

Different models of care Ben – Follow on from the importance of good conversations and link to work on supporting partnerships and providers to explore new models of care.

Neighbourhood care – applying the principles of Buurtzorg Buurtzorg is a model for delivering care in the community developed in the Netherlands Places individual at the centre of their care and is focussed on allowing staff to build good relationships with those they are providing care and support to. Staff are enabled to do this by working in small self-managing teams Ben Values humanity over bureaucracy developed by Jos De Blok Buurtzorg is Dutch word for Neighbourhood Massive success in the Netherlands Teams of district nurses No managers in Buurtzorg, teams are supported by coaches

Neighbourhood care (cont) We are supporting partnerships and a third sector provider in Scotland to develop models of neighbourhood care based on the principles of Buurtzorg Important that these models reflect the local need as well as the wider context of health and social care in Scotland Ben Early stage of work Importance in looking at what rules/protocols are necessary!! – Keep it simple. Teams looking at mix of practitioners across health and social care Some sites not utilising all principles to same extent. Partnerships/providers involved: Borders Aberdeen City Dumfries Highland Western isles Angus Stirling and Clackmannanshire Cornerstone

Intermediate Care Dianne

Intermediate care and reablement can be provided in: The LWiC team are supporting health and social care partnerships to maximise the impact and effectiveness of intermediate care and reablement services. These services offer alternatives to hospital admission, support timely discharge from acute care and help people to regain their independence. Intermediate care and reablement can be provided in: individuals’ own homes, sheltered and very sheltered housing complexes, designated beds in local authority or independent provider care homes, designated beds in community hospitals. Dianne

Intermediate Care at home Step down beds in care homes    Step down beds in care homes   Step down beds in community hospitals Step up beds in care homes Step up beds in community hospitals Hospital at Home Dianne

An episode of specialist care delivered at home as an alternative to being treated in an acute hospital environment and where the care is overseen by a consultant. Care is usually at home but could be in a care home if the individual is usually resident there . Dianne

Visit 1 Visit 2 Consultant 09:00 Ward Round Advanced Practitioners Support staff Admin support 09:00 Ward Round H@H service 08:00 – 18:00 7 days/ week Visit 1 Visit 2 Dianne

Dianne

Strategic Commissioning Thomas

Strategic partners group Strategic Plan Local authority social care budget NHS board budget (for delegated services) Housing organisations Independent sector providers Third sector providers People and their carers What do you need them to know? Consider how they use the evidence about your service and the purpose for them having the evidence. How do you communicate with them? Digitally, face to face, using a template, etc. How often? How often do you need to keep them up to date to influence them? Thomas 31 IA 1 LA 1 Shared 29 Council IJB

Build a story Thomas

Build a plausible story

Visit the ihub stand or: Find out more… Visit the ihub stand or: Website: ihub.scot Blog: www.livingwellincommunities.com Newsletter: hcis.livingwell@nhs.net Twitter: @LWiC_QI Thomas

Thank you…….now over to you! At your tables please discuss your thoughts to what you have heard, in particular: If you could change one thing about your service what would it be? (5mins) 2. What could the ihub do to support you? (5mins) Thomas to introduce

Feedback / Any questions? Thomas

Visit the ihub stand or: Find out more… Visit the ihub stand or: Website: ihub.scot Blog: www.livingwellincommunities.com Newsletter: hcis.livingwell@nhs.net Twitter: @LWiC_QI