Developing Integrated care in GM Building on our Healthier Together Commitments 14th June 2016

Context The Healthier Together made a series of commitments relating to the development of primary and joined up care, (integrated care) across GM. This has given us a platform upon which significant aspects of our GM Strategic Plan, “Taking Charge” has been built. This presentation describes these next steps in the context of the wider GM transformation programme. Members will recall the “venn diagram” depicting Primary, Integrated and Acute Care and our ambition to achieve a so called “total eclipse” of the Primary and Integrated Care circles. We believe that the work described in this presentation achieves this objective via the development of our GM Locality Plans and their vision for integrated care serving neighbourhoods of circa 30-50k populations. Scaled, population health and wellbeing management is core to our strategy to transform community based care and support. This part of our new models of care and support are central to our ability to maximise the demand reducing potential of those new models. An understanding of those characteristics of the new models essential to managing population health improvement and reducing demand on acute services is key to ensuring all parts of GM are developing models which will contribute to clinical and financial sustainability

Delivering our ambition: aligning reform across GM H&SC TRANSFORMATION WIDER REFORM ACROSS GM

Proposed method for a consistent approach to developing an LCO 1. Identify target population The 10 stage approach to the left starts to illustrate an overall development approach to fully establishing an LCO. GM colleagues consider the value of consistent approaches at key stages such as: Risk stratification & population segmentation approaches how we define an LCOs core characteristics at both a basic and advanced level to reach for the higher ambition on scope and development A reliable costing methodology inform investment and implementation considerations and a standard GM approach to Cost Benefit utilising the New Economy model, of interventions delivered by an LCO. 2. Assess potential impact by area of spend 3. Use ‘logic model’ to define reinvestment potential 4. Define core elements of delivery model 5. Translate the core elements to activity 6. Identify and model the workforce requirements 7. Model the financial requirement 8. Conduct segment level Cost Benefit Analysis comparing savings and investment 9. Translate into payment mechanisms 10. Identify performance “dashboard” and approach

Key Assumptions & principles Assets & strengths of people & communities Equally involved Carers & Family Integrated Record & Care Plan for health & care needs Involved in decisions on care & support Key Assumptions & principles Use of risk stratification & population segmentation Well managed needs 2 or more health/complex needs Mostly Healthy 3 or more health/complex needs Increasing health and social care needs Resources & approach reflective of intensity of support required People & carers empowered to self care Advice & support Care & support co-ordination Integrated team GP Tailored increase in resources for self-care, carer involvement & primary & social care e.g. longer appointments, same day access, social prescribing, 24/7 cover Home pharmacy GP Practice Cluster/Group Better connections of existing teams alongside development of new roles Mental Health Physio Case management Nurse practitioner Pharmacist Clinical lead Physician associate Existing services Specialists Care Co-ordination VCSE New/ emergent roles OT Behavioural health Social worker Extra Care Housing Diagnostics JCP Intermediate Care Network enablers Connecting all who contribute to health benefit Voluntary & Community Sector Wider Public services (housing, fire etc) Diagnostics Community Pharmacy Primary & social care care at Scale 999,111, OOH Acute & urgent care Recognising organisational & cultural development Cultural & people integration: Human to human, individual to team, team to team - local staff moving towards a single organisation Financial Integration: Capitated budgets for a defined population with aligned incentives developed within longer term contracts Systems and operational integration: shared IT & systems supported with robust governance arrangements

LCO’s are likely to be made up of interventions addressing these types of issues: 1 Prevention and health improvement: GM and locality programmes such as EY NDM, work and health schemes, dementia utd, Falls. Improved community and social capital Asset based care through culture and system change Work place health programmes Improved screening and early diagnosis Use of practice registers and patient level data 2 Population level activity: Identification (risk stratification and segmentation) and enrolment in programmes of risk individuals 3 Self care, Independence and well being: Patient activation framework and measures GM and local social marketing campaigns Full use of digital technology for better self management and healthy lifestyles Personal health budgets Patient empowerment and self management programmes such as expert patient 4 Care planning and care coordination Care navigation and communication systems across a range of health and care settings 5 Case management 6 Integrated hospital/care home diversion and discharge: Integrated health and care teams Access to specialist opinion Rapid response teams Virtual wards Aligned intermediate/reablement 7 A health and care system aligned to wider public services: Strong partnerships with: education, skills and work Housing Voluntary sector 8 New models of pricing and contracting: Pricing & incentives to drive improvement in population health Population outcome based contracts for community provision 9 Optimising elective care 10 Better integrated EOLC

Summary and recommendations The Healthier Together Joint Committee is asked to: Note that the work which initially took place in line with the initial Healthier Together commitments has developed as described in this presentation Note that this new phase of work directly connects to the GM Strategic Plan, “Taking Charge” and the development of the 10 Locality Plans Note that each area of GM is developing Locality Care Organisations, in line with the models and characteristics set out in this presentation Consider, in the light of the above, how the Joint Committee wishes to be appraised of progress on this agenda.