Improving Outcomes through Integrated Care Dr Anne Hendry National Clinical Lead for Integrated Care Joint Improvement Team

What Matters to Me >Coordination and continuity of care >Trusted relationships >Accessible information and advice >Good communication with, and between, staff

People living in more deprived areas in Scotland develop multimorbidity 10 years before those living in the most affluent areas

Mental health problems are strongly associated with the number of physical conditions, particularly in deprived areas in Scotland

Public Bodies (Joint Working) (Scotland) Act Bringing together the accountability of statutory partners in an equitable way, to deliver better outcomes for patients, service user and carers - all adults and all care groups. Royal Assent APRIL 2014 Consultation on Regulations and development of Guidance APRIL 2014 – AUGUST 2014 Regulations and guidance complete NOVEMBER 2014 – FEB 2015 Integration goes live locally APRIL 2015 All integrated arrangements must be in place APRIL 2016

2014 National Action Plan for Multiple Conditions Adults with multiple conditions are supported to live well and experience seamless care from the right person when they need it and where they want it. Scotland is a world leader in research, innovation and improvement for Multimorbidity and Integrated Care.

4 Primary Drivers 10 Local Actions on three levels: Individual - care planning and consultations that help people to have control over their conditions, care and support and to achieve their personal outcomes Local team - integrated care and support that builds on community assets and promotes independence, wellbeing and resilience Whole system - pathways that are designed around people with multiple conditions and to reduce health inequalities 5 National actions for Government and Special Boards to drive excellence Adaptive leadership Research, innovation and improvement infrastructure

Technology Enabled Integrated Care

Intermediate Care >Rapid Response / Early Supported Discharge >Reablement >Hospital at Home >Step Up / Step Down community beds

Residential Care Task Force >Personalisation >Capacity Planning >Commissioning >Managing Risk >Fee Structure and Funding >Governance and Quality

>Pathfinder project lead by SCVO with East Dunbartonshire Voluntary Action, Community Health Partnership, Council and local third sector organisations. >Working intensively with a number of third sector organisations to help evidence their impact on community well-being. >Provides training (delivered by Evaluation Support Scotland) to help them identify their outcomes and produce the kind of evidence that will demonstrate their impact. >

Local Partnerships with Third Sector

All Improvement is Local >Locality as the Engine Room of Integration >Where we will best engage and empower those that deliver and receive health and social care >Where service changes can have a real and quick impact on outcomes

Building Trusting Relationships

>working seamlessly with colleagues in NHSScotland and partners who provide care >making more and better use of technology and facilities to increase access to services >strengthening workforce planning to ensure the right people, in the right numbers, are in the right place, at the right time >putting new and extended roles into practice

Integrated Care Support Worker

9 Health & Wellbeing Outcomes (proposed) People are able to look after and improve their own health and wellbeing and live in good health for longer. People, including those with disabilities, long term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. People who use health and social care services have positive experiences of those services, and have their dignity respected. Health and social care services are centred on helping to maintain or improve the quality of life of service users. People who provide unpaid care are supported to reduce the impact that their caring role has on their health and wellbeing. People who use health and social care services are safe from harm. People who work in health and social care services are supported to continuously improve the information, support, care and treatment they provide and feel engaged with the work they do. Health and social care services contribute to reducing health inequalities Resources are used effectively in the provision of health and social care services, without waste.

Integrating Care for and with Jessie