Care Closer to Home Working with the voluntary sector Optimising health and independence

Contents Introduction and vision Drivers for change Outcomes to be achieved Working with the Voluntary Sector

Introduction and vision for CC2H Principles: Patient Centred, empowerment and support for self-management Joined up care Case Management The right level of care – shift to out-of-hospital settings Recovery focus Prevention is better than cure Fundamentals of the contract: 7 year contract worth £237m from April 2016 Delivered £2M cost savings Wrapped around Primary Care Deeper integration with Acute, Mental Health, social care partners 1% ring-fenced for the voluntary sector

Drivers for change The system is not sustainable The resident population of North East Essex is expected between 2012-21 to rise by 13%. This is an older population with increasing prevalence of frailty and multiple long term conditions. This group of patients accounts for: Nearly 70% of health & social care spend Nearly 80% of in patient bed days 55% of GP appointments Nearly 70% of outpatient and A&E attendances 80% of people over 80 have one long term condition, 40% have 2 or more. This means there are huge overlaps in services and we can’t afford to continue to fund this. Proportion of people with long term conditions by Age % with one of more LTC

Transformation over the lifetime of the contract ACE’s role: system integrator Delivered through Integrated Care Teams Patient owned care Leading a range of providers to deliver coordinated community care Organising around the practice to provide a seamless service to patients Supporting patients to take more responsibility for their health and wellbeing

The Care Pathway * Larger version included in packs. * (left hand side) CCG Consultation. Listened to patients and referrers Listening exercises Meetings with referrers Patient panels (right hand side) We designed the model to deliver.

Outcomes to be achieved by CC2H Helping people be independent and improving patient and carer outcomes Helping our local community to be healthier Building a network of integrated services Maximising system resilience & sustainability Innovation driving quality and value for money Helping people be independent and improving patient and carer outcomes: Putting patients at the centre – self care Developing care and support plans – owned by the patient All patients with complex needs will have a care co-ordinator Helping our local community to be healthier: Focusing on prevention and early intervention We know the local communities Building a network of integrated services: We will build on local partnerships and establish new ones to drive integrations through co-development of care pathway. Removing complexity Community Gateway, referral, assessment Maximising system resilience & sustainability Committed to and focussed on North East Essex Working with the supply chain More services within the contract Social Enterprise – investing back Innovation driving quality and value for money Model based on best practice from around the UK and beyond Use of technology Learning from others Innovative workforce Support to self-care To support clinical care Over the life of the contract move from Provider to System Integrator. Contract 7 years

But this can’t be achieved by ACE alone Need to work in much closer partnership with the voluntary sector Design solutions together – weave these effectively into our services Share information – communicate regularly at all levels Develop a 7 year strategy – won’t achieve everything over night

Next Steps Developing a longer term strategy with Colchester and Tendring CVS Starting with 2 key priorities: Self-management Promoting independence More details available in the Care Closer to Home Workshop