Integration – personalising care, linking social care with health Mark Leach Project Manager – Ealing Integrated Model of Care 2015/16

See for yourself https://itnproductions.wistia.com/medias/qpl4wm4thn

Whole Systems Integrated Care Part of the North West London Early Adopter Whole Systems Integrated Care Homeward is Equivalent to Community Integrated Service which was part of the Hammersmith and Fulham offer Co-design in 2014/15 200 stakeholders in Ealing – similar to other 8 boroughs West London developed Hubs where wrap around care was delivered from a central point - Charles Centre

Prototype Phase Governance Implementation Group included all providers, Healthwatch, Carers Centre, Mencap, Age UK Senior Sign off from Better Care Fund and Health and Well being Board The offer Co-ordinated care for people over 75 with one or more long term condition in 3 Practices from March – October 2015 through a Care Co-ordinator and a Joint Care Team

Multidisciplinary Team

Social Care Met with the Acting Service Manager Mapped out all social care processes Identified where care co-ordinators could effect change Worked with 100 people Case Studies Studied Case Studies at Implementation Group Action Learning sessions for Care Co-ordinators with Professor David Sines

Case Study Background Practice nurse came back to practice after visiting an octogenarian couple. Husband was a wheelchair user who needed support from his wife who was his carer. The woman had been invited to have a mastectomy operation but she was not going to attend because there was nobody to care for her husband The care co-ordinator received the referral. What we did Care co-ordinator met with family, then linked the multidisciplinary team around the family. Co-ordinating care through emails, telephone conversations and face to face discussions. Through senior social worker they were able to set up an emergency care package and time in the operation. What was achieved Operation took place within a week of the referral without any cancelled appointments. Family felt in control of the care around them.

Case Study From the Film Background Woman had been to hospital for unplanned admissions twice in a week. Housing issues caused some difficulties with conflicts over room with family members. The person had COPD and was frustrated by her potential inability to see her grandchild’s christening. Intervention Care Co-ordinator met with woman found out what her goals were. Got her a Medication Review with the pharmacist, ordered a wheelchair, Taxi Card and Shop mobility membership. What was achieved Woman felt better after being shown how to use her inhaler properly. She became independently mobile with the wheelchair and hasn’t been back to hospital as an unplanned admission in 8 months. She went to her grandchild’s christening

Professionalising the new model -Diploma in Integrated Care Care Co-ordinators received four days training on Integrated Care and Whole Systems Monthly action learning Plans to register with a University Build 3000 word essay and a Portfolio of work Joint Care Team undertook Coaching for Health Training to set the conversations so that the older person would be in control of their own health as much as possible

Lessons Learned Plan, Do, Study Assess Project management method learning lessons and dealing with risks straight away Fortnightly North West London Project Managers Check Point Meetings Action learning sessions Care Co-ordinators learning logs Lessons Learned Interviews with key stakeholders Health Watch Focus Group Nuffield Evaluation of Whole Systems Integrated Care

The strengths A strong sense of ownership through co-design across North West London Strong communication skills from care co-ordinators An understanding of the different sub cultures and professional language Professionalisation and building from a solid base

Areas to develop Accountable Care Partnership routed in the local knowledge economy Recruitment was slow initially and there has been a lot of turn over, professionalising will enable the Integrated care teams to keep staff longer Care Navigation getting to older people early Business intelligence needs to develop qualitative and quantitative measures

My new role – Improving Value Programme Manager PMO for the Improving Value Pipeline From Idea to Implementation Pack for Transformation Projects Cost improvements, Quality of Life, Improved clinical outcomes

Gateway Process Ideas for transformational change Ideas are discussed with the Improving Value team. 4 key questions for Gateway If the 4 conditions are met the Ideas goes through Gateway 1 and the Project team put the Project onto a Scheme on a Page Scheme on a Page goes back to the Programme of Care to approve and the Improving Value team Business case is developed and approved by the POC Board and Improving Value Board Implementation Pack is developed and this is then shared with the Regions to Implement Project Review