Integration – empowering people to stay at home NHS Great Yarmouth and Waveney Integrated Care System “Nothing between us that we cannot resolve.”
Introduction Great Yarmouth and Waveney
The Integrated Care System
ADMISSIONS AVOIDANCE Reduce unplanned care admissions Keeping people out of hospital DISCHARGE Early assessment Timely Care in right place Avoid readmission UNPLANNED CARE Early diagnosis Right care, right place Reduced length of stay One team One ICS One commitment One shared vision Seven Day Services PERSON Initial Key Focus Areas
Patients told us it’s what they want – to stay at home It offers - Better patient experience; retain independence Recover faster & more fully Improved dignity Reduced exposure to communal acquired infections It helps the GY&W system - Reduced number of emergency admissions Reduced length of stay / timely discharge Reduced reliance on long term care placements Patient, Family, Carer GP Independent Nurse Prescribers Senior Community Nurses & Therapists Social Work Practitioners & Assessors Rehabilitation & Re- ablement Practitioners Generic Workers Community Phlebotomists Day Coordinators (Health) & Duty Workers (Social) Administrators Why a 24/7 Out of Hospital Model? Beds With CARE
The Integrated Community Care Hub Kirkley Mill, Lowestoft Out of Hospital Team GPs, in and out of hours Therapists and Podiatrists Community Nurses and Phlebotomists Social Work Practitioners Community Mental Health Practitioners Paramedics Pharmacists Community Support Workers
Case Study Before Taken to her bed Malnourished Dehydrated Not taking medication Dog and human faeces Joint Assessment within 2 hours of referral After Medically stable Managing medication Self caring – x 1 daily carer Attendance allowance Safe and clean home
Measures QualitativeQuantitative KPIs Activity Bed usage Other Clinical Service Reviews System Finances Patient Feedback “Making my life much easier than it would have been without their help.” Staff Feedback “Able to provide better and quicker care.” Culture Change Job Satisfaction Measuring Success
Our Learning Whole system approach Leaders commitment Clinical/professional steering/design Communication Detailed planning ‘Plans breakdown in the face of the enemy’ so take feedback and evolve Significant workforce/HR issues Be bold
Photographic images used in this presentation were sourced from: NO COPYRIGHT INFRINGEMENT INTENDED Andy Evans Chief Executive Officer NHS Great Yarmouth and Waveney CCG Adele Madin Director of Adult Services East Coast Community Healthcare Shaun Overy Area Manager for Adult Care (Waveney) Suffolk County Council References