1. Developments in Out of Hospital Care
24th May 2017
Annette Bunka –Senior Commissioning Manager

2. 2016/17 Summary First year of new community services provider, CLCH.
An increase in the workforce to support people in their own homes and in particular to support rapid response services in the community.
Community health and social care services are now co-located, paving the way for greater integration of services within 2017/18.
A case finding pilot was undertaken looking at proactive support to those who may have frailty.

3. Priorities for 2017/18
Integrated locality teams, including roll out of frailty pilot and review of frequent attenders
Rapid response and intermediate care, including discharge to assess
Improved end of life care and in particular care planning
Enhanced support to care homes (and learning from Vanguards)

4. Integrated locality teams
Build on existing community based health and social care infrastructure
Focus on proactive support for adults with complex health and social care needs.
Develop the support available to those with different levels of frailty and in particular identify those ‘below the radar’.

5. Rapid response & intermediate care
Improve integration between reablement and rehabilitation services
Discharge to assess: home-first principles
Expansion of the multi disciplinary team and improvements in the skills to support those in care homes and intermediate care facilities
Support hospital transfer pathway and use of ‘Red Bag’

6. Proactive support in the community
Frailty develops as a result of a decline in physical and functional systems which results in vulnerability to sudden health changes (e.g. which could be triggered by an infection or fall)
If frail older people are support to live independently, understand their long term conditions and are educated to manage them effectively, they are less likely to reach crisis
Interventions could range from supported self management to care/case management to anticipatory care planning and end of life care

7. Support required to deliver this
Community services, in particular case managers & care navigators recruited by CLCH
Health liaison social workers from LBM
GP practice input
Voluntary sector
Patient/public involvement in the development of this work and in particular the approach to be adopted and the materials to support people and their carers.