1. Implementing an integrated Health and Care model Keeping people living healthily and independently for longer

2. Our aims Support people to be healthy and more independent for longer Communities are easy and supportive places to live with a health or care need Reduce costs of health and social care Create a system that is rewarding to work in

3. Looking at a system wide locality approach CCGs Acute hospitals Community Health Mental Health County Council – children and adults and Public Health District and borough councils Voluntary and community sector Police Ambulance service

4. People get the right response, at the right time in the right location when things do go wrong. PROactive REactive

6. Implementation Local populations Connect early adopter sites Cohorts of individuals High demand customers Early intervention teams Care homes project Scaling up across the whole system Proactive Reactive

7. Sudbury East Ipswich Chose areas with strong GP leadership, confident social care teams, and a vibrant voluntary sector Multi-agency project groups established Engagement events Work streams -Integrated Neighbourhood Teams -Neighbourhood Networks Connect early adopter sites

8. Proactive care Give people the tools they need to stay healthy

9. Managing high demand Risk stratification: –Frailty assessment of over 75s on admission –Frailty assessment of all people with 3 or more LTCs –Three or more emergency admissions in 3 months –Three or more A&E attendances in 3 months Case review and MDT –Interface Geriatrics and primary care Care and support plan –Integrated around the individual Care coordination –Single contact, no wrong door

10. Early intervention teams Community based model Multi-agency (health, social and voluntary sector) crisis resolution with focus on return to independence Rapid holistic assessment within 2 hours of referral Deep dive into all current admission avoidance schemes to establish –Good practice –Pathway redesign –Areas of improvement/efficiency –Training and development needs Crisis Action Team (CAT) & Enhanced Intervention Team (EIT) piloted from October 2015 Host organisation will deliver service and sub-contract to all agencies (CAT aims to deliver a minimum of 3.5 reduced admissions per day of which 20% are 0 LOS and 80% are >1 LOS) and reduced number of ambulance conveyances to hospital Host organisations (Acute Hospitals) to facilitate joint pathways with front door and frailty services (Frailty Assessment Base piloted in October 2015 aims to deliver a minimum of 2 reduced admissions per day)

11. Supporting care home residents 135 care and support plans and 265 advanced care plans in place –Shared with OOHs GPs, 111 and ambulance –Supported by named care coordination 35% reduction in care home emergency admissions on targeted cohort Improved coordination and response to end of life care – supporting people to die with dignity at home

12. Lessons learnt Coordinating across organisations and work streams is time consuming – but no need to change structures – build, learn and keep what works Pace of change can be slow – looking back you will see progress and can celebrate the successes Keep stakeholders informed

13. Thank you for listening Clare Banyard – Ipswich and East Suffolk CCG – clare.banyard@ipswichandeastsuffolkccg.nhs.uk clare.banyard@ipswichandeastsuffolkccg.nhs.uk Jo Cowley – Suffolk County Council – jo.cowley@suffolk.gov.ukjo.cowley@suffolk.gov.uk Sandie Robinson – West Suffolk CCG – sandie.robinson@westsuffolkccg.nhs.uk sandie.robinson@westsuffolkccg.nhs.uk