1. Health & Adult Social Care Paul Little Head of Strategic Commissioning Suffolk County Council - Adult and Community Services
What to talk about the whole system
Will cover how the whole system approach affects hospital admission and discharges
Will be speaking for about mins to allow plenty of time for comments or questions; any questions I can’t answer will happily provide a written response to the Chair

2. Today we I will be covering:
How Health and Social Care services are working together to deliver the best services we can for the people of Suffolk The progress we are making in West Suffolk How we plan to develop things in the future
Look at the whole system with reference to the main themes above
Will cover these in relation to three key areas; keeping people keep well and out of hospital; getting them help to stay put of hospital if hospital is not needed; helping them to recover when coming out of hospital so they regain independence

3. The Health and Social Care System
Acute Services – clinical care delivered in and from Hospitals
Community Health Care – GPs, Occupational Therapy, District Nurses, Physio Therapy etc.
Social Care Services – Home Care, Specialist Support Services, Supported Housing, Day, evening and weekend services, Care Homes and Social Work
To give context to presentation on the whole system this is a Broad description of the main bits of the system

4. The Health and Social Care System
Our Aims are:
To make sure people have access to the right services for their needs
Prevent unnecessary hospital admissions
Help people to fully recover independence following hospital treatment
Enable people to managed their own care and wellbeing
To provide Integrated Care
These broad aims are fundamentally about getting the right care and support to people when they need it, with thee aim of reducing the impact of any episode of illness on their longer term health and welfare.
Its essentially about a) keeping people well b) helping them quickly at as early a stage as possible to stop things getting worse and c) helping them to recover when they do need acute services
DTOCs are a whole system issue
So if the GP cant see you….. if the admission prevention service is full…… if the INT isn’t up and running very well then you are more likely to be admitted.
If ED is staffed by junior staff, not the consultant who is much more pro risk…. If you end up on a ward which is staffed by agency….. If there in no in reach from the community….. if you are sitting around in bed because staff are too busy to get you up, you are more likely to need social care.
The more people are referred to social care, the more likely you are to have to wait, as the care market can’t keep up with demand.
Reablement is partly about breaking the cycle.

5. What do we mean by Integrated Care
At its heart, it can be defined as an approach that seeks to improve the quality of care for individual patients, customers and carers by ensuring that partners understand the needs of the local population and services are well co-ordinated around their needs. The Integrated Neighbourhood Team is a multi-agency team, committed to this approach
Integrated Care – easy too say, but more difficult to do of course – this is the core definition that all partners are signed up to……
In terms of the whole system lets start by looking at health and social care community based services and our efforts to join those up around localities, called INTs

6. Working Together – Integrated Neighbourhood Teams
The Background:
Health and Social Care have fully signed up to integrated care providing better health and care system for people – but this is not easy
The Health and Care Review created a shared view of a future integrated system
The vision and service model has been signed up to by all partners, and has informed the Suffolk Better Care Fund Plan
Partners are now committed to delivering the new model of care – Connect Sudbury and Connect East Ipswich were the forerunners for the new system
Connect is strapline for Integration of health and care services
By way of introduction Some background to the INT
National plans signed up with Councils and the NHS – full integration by 2020
This work is very much underway but it’s a whole system transformation and it will take sometime to turn this particularly tanker around….
In Suffolk we call this programme Connect

7. The Connect Programme A community based approach for a new way of working
Suffolk Health & Wellbeing Board - Health & SC Review
People Manage their own health + care
Communities are supportive places to live
Health + care system is co-ordinated
Interventions are matched to people’s needs
Care Act Introduces new responsibilities for LAs
Prevention
Information & advice
The provision of high quality, appropriate services
LAs need to;
Consider services & resources in their area e.g. voluntary & community
Work with other partners, like the NHS
Community Resilience
INT
System transformation about localities to community and indivduals resilience under sara blake on PH Clare Smith coordinating the system ACS strategic lead (ops teams normal) – important connection to locates and the nature and strengths of particular communities
Need to coalesce around locality dynamic
Making this happen through 4 implementation managers – funded by TCA to push the stuff together, drive the projects forward project planning etc 4 people 2 in west and 2 in east and south….
Context of these overall aims:
People Manage their own health + care
Communities are supportive places to live
Health + care system is co-ordinated
Interventions are matched to people’s needs
INT Vision
Promote + enable self-care
Prevent ill health + crisis intervention
Provide access to local multi agency services

8. Key elements of an Integrated Neighbourhood Team (INT)
Early intervention
Local Area
Co-ordinator
VCS
Self Management
CYP
Prevention
District/ Borough Council
Understanding each other
INT Directory
Workplace shadowing
Learning Events
ACS
Making integration Happen
Sitting in the same place
Project management / comms
Sharing Information GP
Primary care
Key elements:
Acclimatisation (on the left)
Creating the condition for integration to happen (on the right)
Delivering (bottom middle)
Suffolk Community Health
Home First
Police
Housing
Interface Geriatrician
Mental Health Wellbeing Link Worker
Person centred
Joint processes and protocols:
Joint reviews for care co-ordination
Shared care and support plan
Regular joint meetings

9. Impact of INTs
Patients / clients and their family carers will experience:
Improved managed or coordinated care with fewer handoffs and service duplication
Consistency in how care is delivered
Improved local delivery in their own home or usual place of residence
Improved empowerment through delivery of shared decision making, integrated focus of self management and reablement
The health and care system will experience:
Improved collaboration and communication
Better understanding of pathways and operational processes
Reduction in administration
Local ownership of integrated delivery
This is why we are doing it and what we are confident will be the benefits

10. INTs Progress so far West
Sudbury – HomeFirst, OTs, LAC all hotdesking in ACS offices. OT joint working practices established. SCH & ACS delivery of joint training. Active links with VCS in place.  
Forest Heath – Mildenhall Joint OT meetings and case management in place. Connect Wednesdays events held in Mildenhall District Council Offices & Newmarket Hospital
Haverhill -  INT established, work started on directory, ‘Lunch and Learn’ sessions scheduled, INT engaged with Social Prescribing project
Bury Rural – Care co-ordinator appointed to aid MDT performance , work started on directory, ‘Lunch and Learn’ sessions scheduled
Bury Town – INT established, Frail elderly project launched, work started on directory, ‘Lunch and Learn’ sessions scheduled
Definition of what joint working looks like community OTs and home first to focus on reablement
Frail elderly project……risk profile to find vulnerable at risks of falls or repeated hospital admissions to coordinate services (focused on over 85s…) to keep them well in the community and community resilience
Int established meeting and working together and case around MDT (GP led and are around sw ch around complex cases and needs)
Joint visits: “In one particular case a son felt his mother should be in a home as he was so concerned about her mobility and ability to manage various tasks. I visited with an OT and Physio and together we were able to alleviate some of the son’s concerns and put strategies and support in place for the mum. He told me afterwards that he had got so stressed with the situation but he felt very supported by all the services. It was interesting for me because the physio was able to explain how the customer’s illness was affecting her mobility, and actually she was much more able than she actually appeared.”
“Overview: Male customer living in private rented house was neglecting personal care, nutritional needs and medication. Socially isolated he had no contact with any friends only family when they had time to visit. He enjoyed colouring in intricate colouring books and enjoyed sharing the finished pictures. The DIS Team became involved supporting him with personal care, and social opportunities. Support worker from DIS team wanted to get one day a week at Age UK funded and home first support to encourage personal care, encourage eating and prompting meds. His personal care needs were met, and Age UK was a success, but at a cost of £44.00 a day. We then looked at social support closer to his home and the customer was introduced to staff at local sheltered accommodation and invited for lunch to meet with other residents. He was so happy to be able to chat with other residents and have lunch with other people, he was invited to stay for afternoon activities. Which he really enjoyed. This was made a permanent arrangement at a cost of £15.00 a day to cover the cost of a carer to collect customer from his house opposite, the activities, and a carer to walk customer back home at tea time, in time for the care visit.

11. People being Discharged from West Suffolk Hospital
Sometimes people are delayed from leaving hospital (“delayed transfers of care”) Delays at West Suffolk Hospital are much lower than other hospitals and the situation is improving with a 62% reduction in delays (comparing September and latest figures available for Jan) The primary reason for delays is usually getting people the support they need so that they can go home Delays can also arise when arranging 24 hr care for someone when they are the responsibility of Social Care. This is one reason why we are doing so much work to improve the care market Delays also arise through delays in arranging appropriate health care to support people post a period in hospital

12. What is being done about these delays – A Planned Response
Part of the reason for the delays arise from the volume of people being admitted to hospital in the first place Health and Social Care are working together to develop Integrated Neighbourhood Teams (INTs) who can more readily recognise emerging escalating needs and address these, rather than allow needs to escalate to a point where hospital admission is required: Prevention is the key
So this just emphasises the whole system approach again –
We covered the approach integrating community care
In addition there are some vert specific pieces of work underway with hospitals to ensure people can be discharged quickly, safely and with a properly planned recovery

13. What is being done about these delays – The Reactive Response
Integrated Early Intervention Team (EIT) provided by West Suffolk Hospital but including nursing staff, therapists, social workers, support workers and voluntary sector support EIT responds to crisis situations that might lead to a hospital admission taking referrals for people at home or who have attended A&E, with a view to avoiding hospital admission, stabilising the situation and drawing in ongoing care and support where necessary
Some overarching projects specific to West Suffolk
Fully integrated team to provide help and support to people in the community and keep them out of unnecessary hospital admissions
All about getting the right help from the right people at the right time

14. People’s experience in Hospital
Care Coordination – Enhanced Recovery and ‘No Wasting of Patient’s Time’
Acute care is a series of dependent steps.
Unnecessary waits/variation in lead times, addition of additional unnecessary steps etc create errors and harm.
Red bed days vs Green bed days
Unnecessary Waiting + Sleep Deprivation = Deconditioning
Wait
Care
Sleep
National research to describe and point out people’s reality of life in hospital – unproductive and wait times not good fro people’s recovery. Interrupted (Deconditioning) moves to more regalement work on wards and aid recovery rather than just leaving them in bed (more active management). Not sure if this is translating into other hospitals
The Ian Sturgess slide: I think it’s important to say that there is loads of work going on nationally around ‘pj paralysis’ it how harmful it can be for people to be in hospital, in bed….. any longer than they need to be
National understanding about started patient matters and part of the whole journey – move to reported number of stranded (anyone over 7 days stay)
Assessment and Discharge risk screening
What was important medically, physically and socially?
Estimated date of discharge
Patient flow can be characterised as series of examinations, investigations, interactions and periods of waiting in between these milestones
a progression through an admission episode delineated by delays that are inherent in health.
Key issues identified by clinical redesign projects are system delays in patients accessing diagnostic testing referrals to other services including medical consults allied health etc..
This can be a that the admission point, during the admission and even at the end of the hospital stay wait for a diagnostic test to provide a discharge readiness decision
When should he have gone home
Multidisciplinary team meetings
What were his realistic options? Could it have been done from home?
Communicate patients EDD to patients and cares
Did the plan meet the patients and families needs?
Understanding patient flow allows organisations great insight into how to improve hospital efficiency and care delivery
By reducing the waiting time overall LOS is reduced without changing the clinical care received by the patient 14

15. Discharge to Assess – A new Approach
Hospital is the wrong place to assess people’s ongoing needs:
It takes time to do properly
People’s presenting needs in a hospital bed are different (and often higher)
than those outside of hospital
Glastonbury Court as a “step-down facility”: 24 beds to facilitate people being able to be discharged from hospital to recover, regain optimum independence with a view to being able to return home
Home First (Suffolk County Council’s reablement service) working more closely together with local health care services (see INTs) to support people to return home
Assessing people’s ongoing needs is problematic in hospital
It very time consuming and can in itself lead to delays in discharge
Often not all the right people can be involved to do a comprehseive assessment;; and
Following on from the previous slide people’s state of wellbeing in hospital can be a poor indicator for there recovery plan as they often return to a better stae of health and wellbeing in a different environment

16. The Discharge to Access Appproach
4 pathways
Assessments are better done out of hospital once people true condition is able to reflective – default is go home
Pathway 0 – not need any new intervention and no need to assess long term care clear clinical recovery
Pathway 1 – Need some reablement intervention; do that at home with Home first care package and long term assessment starts straight away and reviewed with social care (CAT + = Admission prevention service and also some sense of outreach) West developing a similar model fro outreach contact too help capacity (extension of EIT).
Pathway 2 – Bedbased – community hospital (have a more reablement focus for including things like physio, OT) active management
Pathway 3 – continuing healthcare beds very specifically to help managed temporary states of confusion and mental health including delusions and hallucinations but for a contained period to move

17. The integrated reablement journey

18. Supporting People to go home
Discharge to Assess Glastonbury Court – Step Down facility Development of Home First domiciliary care service (“provider of last resort”) with increased capacity Support to Live at Home Programme development Support to Go Home service development (joint funded between West Suffolk Hospital and ACS)
Support go home as an outreach service planned – should be online by the end of May clinical, reabblement (therapy led)
Glastonbury court Care UK care Home WSH purchased 24 beds and staffing
Given the importance of home care, this is what we are doing to strengthen that

19. Our approach to the Home Care Market
We are committed to ensuring there is guaranteed good quality and reliable care for customers at all times and across all areas that allow them to remain independent for as long as possible
We are working together with all interested parties to develop solutions that work for and across the whole system
We are increasing the rates we pay providers for care
STLH contract started Sept 2015
We are working with all our providers to understand the challenges they face and enable us to have capacity for more home care in the market.
To date we have:
Supported recruitment campaigns
Offered training via workforce development, looking to run bespoke training for providers
Have a dedicated OT working with providers to develop an enabling culture, support outcome based support planning

20. Support to Live at Home
Just describes how home care is organised in the West, which providers for which area

21. Support to Live at Home
A snapshot of current supply and demand with larger support needs in hours in the darker areas of the map

22. Support to Live at Home
Each working day I take a snapshot of the customers on the waiting list; the measurement is the average of this in Jan and Feb. So low averages mean that generally very few people are waiting for care at any given time, and vice versa. If it would be easier to discuss it quickly in person let me know
 I think the average waiting list in the 2 Bury lots are around 1.5 customers; so not quite zero (it never would be exactly), but very good