1. Our improvement offer to those providing care and support to people at home
12 May 2017
Thomas - Introduction

2. Look at some of the work the ihub does under the following themes:
Plan for the session
Overview of iHub
Look at some of the work the ihub does under the following themes:
Conversations
Different models of care
Strategic commissioning
Your thoughts and questions
Thomas – Outlines what session will cover

3. A national improvement resource for Health and Social Care Partnerships and NHS boards
Thomas – Overview of iHub

4. Support health and social care partnerships help older people and people with complex needs to live well at home or a homely setting.
Thomas to give overview on LWIC team, but mentioning relevance of other programmes/portfolio work.

5. We work with health and social are partnerships to…
Developing a better understanding of local health and social care systems to find opportunities for improvement.
Identifying people who could benefit from preventative support before they have a crisis.
Increasing the uptake and quality of meaning anticipatory care planning conversations.
Designing and testing approaches to delivering community-based preventative support to help people live well at home.
Thomas
Developing the workforce to deliver community-based preventative support.

6. Conversations
Nathan
Importance of enabling staff providing care and support to have good conversations and build relationships that allow discussions on important and sensitive issues.

7. Margaret’s experience
Jean’s Pathway 1. Total cost including GP prescribing £ 18,000
Pathway illustration
Admission days
Admission days
Admission days
Care Home days
Outpatient Clinic
Moved to care home for 39 days
Social Care Assessment
Death in hospital
Hospital admission for 16 days
Hospital admission for 3 days
Hospital admission for 32 days
Jean’s experience
July
August
September
October
November
December
May
June
July
August
September
October
Care package provided
Margaret’s experience
Hospital admission for 4 days
Social Care assessment
Moved to care home for 73 days
Death in Care home
Nathan
Purpose: To illustrate that person-centred, anticipatory care planning can make a difference in people’s experience of care.
Narrative: Please meet Margaret and Jean. Two people with similar backgrounds and medical conditions but difference experiences of care in later life.
Margaret had an anticipatory care plan to outline her wishes for her future care before she experienced her first hospital admission. Jean did not.
Jean did not have a anticipatory care planning conversation before she was admitted to hospital. Acute services didn’t know what was normal for Jean or what she wanted for her care. This resulted in longer, multiple hospital admissions and she died in hospital, instead of in a homely setting.
Margaret’s anticipatory care plan was shared with acute services via the electronic key information summary. This help acute staff understand what was normal for Margaret, her wishes for her care and the outcomes she wants to achieve in life. This helped her get home quicker and get the care she wanted.
This demonstrates an opportunity to improve quality of care, which reduces the demand on services (52 bed days vs 4 bed days) and is more cost effective (£18,000 vs £7,100).
Admission 1. 4 days
Care home days
Margaret’s Pathway 2. Total costs including GP prescribing £7, 100
Data provided by Information Services Division at NHS National Support Services

8. Search for
Jack’s story ACP
Nathan

9. Nathan

10. Nathan
Also mention palliative care work

11. Different models of care
Ben – Follow on from the importance of good conversations and link to work on supporting partnerships and providers to explore new models of care.

12. Neighbourhood care – applying the principles of Buurtzorg
Buurtzorg is a model for delivering care in the community developed in the Netherlands
Places individual at the centre of their care and is focussed on allowing staff to build good relationships with those they are providing care and support to.
Staff are enabled to do this by working in small self-managing teams
Ben
Values humanity over bureaucracy developed by Jos De Blok
Buurtzorg is Dutch word for Neighbourhood
Massive success in the Netherlands
Teams of district nurses
No managers in Buurtzorg, teams are supported by coaches

13. Neighbourhood care (cont)
We are supporting partnerships and a third sector provider in Scotland to develop models of neighbourhood care based on the principles of Buurtzorg
Important that these models reflect the local need as well as the wider context of health and social care in Scotland
Ben
Early stage of work
Importance in looking at what rules/protocols are necessary!! – Keep it simple.
Teams looking at mix of practitioners across health and social care
Some sites not utilising all principles to same extent.
Partnerships/providers involved:
Borders
Aberdeen City
Dumfries
Highland
Western isles
Angus
Stirling and Clackmannanshire
Cornerstone

14. Intermediate Care
Dianne

15. Intermediate care and reablement can be provided in:
The LWiC team are supporting health and social care partnerships to maximise the impact and effectiveness of intermediate care and reablement services.
These services offer alternatives to hospital admission, support timely discharge from acute care and help people to regain their independence.
Intermediate care and reablement can be provided in:
individuals’ own homes,
sheltered and very sheltered housing complexes,
designated beds in local authority or independent
provider care homes,
designated beds in community hospitals.
Dianne

16. Intermediate Care at home Step down beds in care homes   
Step down beds in care homes
Step down beds in community hospitals
Step up beds in care homes
Step up beds in community hospitals
Hospital at Home
Dianne

17. An episode of specialist care delivered at home as an alternative to being treated in an acute hospital environment and where the care is overseen by a consultant.
Care is usually at home but could be in a care home if the individual is usually resident there .
Dianne

18. Visit 1 Visit 2 Consultant 09:00 Ward Round Advanced Practitioners
Support staff
Admin support
09:00 Ward Round
service
08:00 – 18:00
7 days/ week
Visit 1
Visit 2
Dianne

19. Dianne

20. Strategic Commissioning
Thomas

21. Strategic partners group
Strategic Plan
Local authority social care budget
NHS board budget
(for delegated services)
Housing organisations
Independent sector providers
Third sector providers
People and their carers
What do you need them to know?
Consider how they use the evidence about your service and the purpose for them having the evidence.
How do you communicate with them?
Digitally, face to face, using a template, etc.
How often?
How often do you need to keep them up to date to influence them?
Thomas
31 IA
1 LA
1 Shared
29 Council IJB

22. Build a story
Thomas

23. Build a plausible story

24. Visit the ihub stand or:
Find out more…
Visit the ihub stand or:
Website: ihub.scot
Blog:
Newsletter:
Thomas

25. Thank you…….now over to you!
At your tables please discuss your thoughts to what you have heard, in particular:
If you could change one thing about your service what would it be? (5mins)
2. What could the ihub do to support you? (5mins)
Thomas to introduce

26. Feedback / Any questions?
Thomas

27. Visit the ihub stand or:
Find out more…
Visit the ihub stand or:
Website: ihub.scot
Blog:
Newsletter: