1. Integration – personalising care, linking social care with health
Mark Leach
Project Manager – Ealing Integrated Model of Care 2015/16

2. See for yourself

3. Whole Systems Integrated Care
Part of the North West London Early Adopter Whole Systems Integrated Care
Homeward is Equivalent to Community Integrated Service which was part of the Hammersmith and Fulham offer
Co-design in 2014/ stakeholders in Ealing – similar to other 8 boroughs
West London developed Hubs where wrap around care was delivered from a central point - Charles Centre

4. Prototype Phase
Governance Implementation Group included all providers, Healthwatch, Carers Centre, Mencap, Age UK Senior Sign off from Better Care Fund and Health and Well being Board The offer Co-ordinated care for people over 75 with one or more long term condition in 3 Practices from March – October 2015 through a Care Co-ordinator and a Joint Care Team

5. Multidisciplinary Team

6. Social Care Met with the Acting Service Manager
Mapped out all social care processes
Identified where care co-ordinators could effect change
Worked with 100 people
Case Studies
Studied Case Studies at Implementation Group
Action Learning sessions for Care Co-ordinators with Professor David Sines

7. Case Study
Background Practice nurse came back to practice after visiting an octogenarian couple. Husband was a wheelchair user who needed support from his wife who was his carer. The woman had been invited to have a mastectomy operation but she was not going to attend because there was nobody to care for her husband The care co-ordinator received the referral. What we did Care co-ordinator met with family, then linked the multidisciplinary team around the family. Co-ordinating care through s, telephone conversations and face to face discussions. Through senior social worker they were able to set up an emergency care package and time in the operation. What was achieved Operation took place within a week of the referral without any cancelled appointments. Family felt in control of the care around them.

8. Case Study
From the Film Background Woman had been to hospital for unplanned admissions twice in a week. Housing issues caused some difficulties with conflicts over room with family members. The person had COPD and was frustrated by her potential inability to see her grandchild’s christening. Intervention Care Co-ordinator met with woman found out what her goals were. Got her a Medication Review with the pharmacist, ordered a wheelchair, Taxi Card and Shop mobility membership. What was achieved Woman felt better after being shown how to use her inhaler properly. She became independently mobile with the wheelchair and hasn’t been back to hospital as an unplanned admission in 8 months. She went to her grandchild’s christening

9. Professionalising the new model -Diploma in Integrated Care
Care Co-ordinators received four days training on Integrated Care and Whole Systems
Monthly action learning
Plans to register with a University
Build 3000 word essay and a Portfolio of work
Joint Care Team undertook Coaching for Health Training to set the conversations so that the older person would be in control of their own health as much as possible

10. Lessons Learned
Plan, Do, Study Assess Project management method learning lessons and dealing with risks straight away
Fortnightly North West London Project Managers Check Point Meetings
Action learning sessions
Care Co-ordinators learning logs
Lessons Learned Interviews with key stakeholders
Health Watch Focus Group
Nuffield Evaluation of Whole Systems Integrated Care

11. The strengths
A strong sense of ownership through co-design across North West London
Strong communication skills from care co-ordinators
An understanding of the different sub cultures and professional language
Professionalisation and building from a solid base

12. Areas to develop
Accountable Care Partnership routed in the local knowledge economy
Recruitment was slow initially and there has been a lot of turn over, professionalising will enable the Integrated care teams to keep staff longer
Care Navigation getting to older people early
Business intelligence needs to develop qualitative and quantitative measures

13. My new role – Improving Value Programme Manager
PMO for the Improving Value Pipeline
From Idea to Implementation Pack for Transformation Projects
Cost improvements, Quality of Life, Improved clinical outcomes

14. Gateway Process Ideas for transformational change
Ideas are discussed with the Improving Value team. 4 key questions for Gateway
If the 4 conditions are met the Ideas goes through Gateway 1 and the Project team put the Project onto a Scheme on a Page
Scheme on a Page goes back to the Programme of Care to approve and the Improving Value team
Business case is developed and approved by the POC Board and Improving Value Board
Implementation Pack is developed and this is then shared with the Regions to Implement
Project Review