Integration – empowering people to stay at home NHS Great Yarmouth and Waveney Integrated Care System “Nothing between us that we cannot resolve.”

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 Single Point of Access

The Integrated Community Care Hub Kirkley Mill Campus, 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 Pharmacists Community Support Workers

Lowestoft Out of Hospital Team; April to August 2014 ReferralApr-14May-14Jun-14Jul-14Aug-14Total ReferralApr-14May-14Jun-14Jul-14Aug-14Total “Making my life much easier than it would have been without their help” Out of Hospital Team Beds with Care

Lowestoft Out of Hospital Team; April to August 2014 “Able to provide better and quicker care”

Lowestoft Out of Hospital Team Emergency acute admissions Age 35 plus Lowestoft Variance April to July April to July % % Remainder of GY&W April to July April to July % SUS Data – (April to July) “It helped me walk quicker” Changes in occupied bed days (April – July) Emergency Admissions April to July April to July %

Case Study Before Patient known to have dementia Frequent dizzy spells Recurrent falls over 5 day period Wider family struggling to cope Joint assessment within 1 hour of referral, including full bloods After Appropriate equipment in the home Spouse able to assist with exercises Medications review Carers in place Wider family reassured of safety Mental Health Services informed