Developing Reactive and Proactive Care Models 2016/17 GP Education and Training Event 22 June 2016 Dr John Oates / Mark Cooke / Julie Taylor For any queries regarding the development of the models please contact: Proactive Care – Mark Cooke, Senior Transformation Lead on 01473 770292 Reactive Care – Julie Taylor, Transformation Lead on 01473 770168

What is Integrated Care? Everything which is not planned! The objective is to commission joined up services which successfully meet acute needs. Ideally mobilise care at or before a crisis determines the intervention e.g. admission avoidance (CAT and FAB)

Proactive and Reactive services Development of two separate strands of commissioned service Proactive Services seek out need and support individuals to maintain or improve their health and fitness to prevent crisis Care is delivered where possible in and around the patient's home or community Using urgent services only if and when necessary Reactive Services: Coordination of the urgent response across providers Joined by a "single point of access“

Reactive and Proactive Care Models The vision for the future Public and Professionals Signpost to relevant local services Single point of access Self-care Advice Care Coordination Function (Professional Clinical Advice and Triage) Case handed onto local Connect Team (Integrated Neighbourhood Teams (INT) and/or Neighbourhood Network (NN)) to respond PROACTIVE MODEL Case handed onto local crisis response function ie REACTIVE MODEL Could GP OOH service be included in this function? Pull based discharge for D2A and DTOCs Community Hospitals Community reactive response team Front door IHT Discharge to Assess (D2A) Delayed Transfers of Care (DTOC) Community Clinics GP Federation Ultrasound Service Community reactive response team Specialist services for advice/guidance Could these be used differently to step people up/across or support D2A function?

Reactive and Proactive Care Models Aims and Benefits Adaption of the urgent care system to reflect the ageing population with multiple co-morbidities. Redesign of the current care system with increasing focus on personal, social, mental and physical health needs Development of a sustainable service model To support the acute Trust to identify patients which could be better managed in a home or community setting avoiding hospital admission.   Benefits to patients Increased patient choice Improved patient experience and confidence in alternatives to hospital based care Access to an appropriate care setting for medically stable patients.

Reactive and Proactive Care Models What is in progress? REACTIVE CARE Implementation of FAB 7-day working pilot Review of future use of Community Hospital beds. Acute delirium / dementia best practice pathway Discharge to Assess (D2A) system to support early discharge. Development of a hospital domiciliary care model Review of Psychiatric Liaison Service Integration of admission prevention functions, built around the CAT team in a 7 day model

Reactive and Proactive Care Models what is in progress? Ipswich and East Suffolk will have 8 geographically aligned areas for roll out of Connect (comprised of Integrated Neighbourhood Teams and Neighbourhood Networks) Agreement that 2 areas will roll out Connect in full Ipswich and East Suffolk area during 2016/17 Agreement that remaining 6 areas will roll out the Integrated Neighbourhood Team component of Connect in 2016/17 Project start dates scheduled for all 8 areas

What does this mean to you? What is the role of Primary Care in a Single Point of Access for urgent care? Integrated care networks of proactive care are geographical, how does this fit with primary care at scale?

Plan for an Integrated Suffolk Health and Care System Approved in January 2015

Reactive and Proactive Care Models Interlink between proactive, reactive and single point of access