Salford Integrated Care Programme Learning from Integrated Care

Our Challenges

Salford Together Updated to show expanded partnership arrangements with VCSE – our community asset based approaches underpin the programme. We have a signed MOU with VCSE to show our commitment to working together as an equal partner. GMTF funded partnership lead sits at provider board and ICAB CCG investing heavily in VCSE and third sector (particularly to support self care/ social px and low level mental health and wellbeing) – they are leading the Wellbeing matters programme – and supporting neighbourhoods by having a dedicated community anchor organisation and a community connector post who support the social prescribing model in each NBH

Adults programme priorities Improving access to GP and community services Sharing information Neighbourhood Teams Services that can help at home or in the community Improving Care and Support Pathways Maximising independence

Care Closer to Home – Neighbourhood Services Five Neighbourhood Footprint 12 month aims Review Neighbourhood health and care needs Agree priorities for integrated working Engage with communities on priorities Look for innovative approaches to harness community assets Delivering care closer to home Proactive management of people with the most complex, long term health and social care needs Preventing those at risk of becoming dependent by proactive early intervention Improved care co-ordination, access to care pathways and optimising the skills and resources in Neighbourhoods Improving access to GP’s and community services Different offer of community and primary care services, through care navigation Support the transformation and sustainability of primary care

Pathways of care: falls New pathways and referrals process launched in March 2018 Referrals starting to increase to falls service. Seeing early signs of reductions in falls admissions Key message – only recently scaled up but there is emerging evidence that this makes an impact on falls reduction Real change will only happen if we get the support of those people who are working with people who fall or who are at risk of a fall. To this extent we launched our new system wide pathway in March 2018. A range of partners are now using three falls questions to identify those at risk and are then seeking consent and refer when risk is identified. Referral processes have been simplified offering electronic referrals to a range of professionals into a single point of triage. People referred can then be rapidly matched to the intervention they need whether this be high intensity (multi-factorial assessment and intervention; medical assessment; medication review) or low intensity intervention from our partners in Salford Community Leisure (postural stability or maintenance classes). As well as expanding the classes available we are also offering Tai Chi as an additional form of strength and balance training and helping to signpost people to community assets where no clinical intervention is needed.

Learning from Falls Benefits: Collaborative working – allowed extensive mix of skills/background and also widened the reach One agenda and standardised key messages: 3 falls questions; 6 key messages re: falls prevention; Key aim to include a prevention agenda Strengths based approach Challenges: All stakeholders have different governance structures, but opportunity to push boundaries Different cultures within organisations – decisions may impact on risk, ie people’s rights, etc Key message – its early days but realistically this could have us managing 200-300 key risk patients proactively to stop them coming into the urgent care system

Conclusion Recognition that we have ability to solve issues/challenges through collaborative working Opportunity to further explore this afternoon in workshops How do we support people living well and keeping well? Promotion of independence and self care Opportunity for all to contribute and shape the frailty agenda, as we all bring different skills and resources Key messages – these are the next immediate steps, we know what we need to do and are on with it. Most of them happen within Q3/Q4 this year