1. Phase 2 TARGET OPERATING MODEL
COMMUNITY INTEGRATED SERVICES
Phase 2 TARGET OPERATING MODEL
Insight
informing
design..
We put quality first We focus on people We take responsibility

2. COMMUNITY INTEGRATED SERVICES – PHASE TWO
Management for Change
Phase One Completion July 1st
Target Operating Model
Long term vision for Community Integrated Services

3. INDIVIDUALS’ EXPERIENCE
“Would be better if you knew what times they were coming, but realise this is not possible.”
“3.5 wks delay in Assessment, findings wrong, not satisfied with result. Expected to be assessed at home, feel this assessment not good without personal visit.”
“There is no regular review of whether my care needs are still adequate for me. With changes that have happened in the Service Team, I do not know the name of the person assigned to me!”
“When you listen to me, don’t do it over a form and a time limited chat, get to know me, understand how and why I live the way I do, actually invest time in me! make sure i have just one person to speak to who sorts it all out for me. I get fed up of talking to 20 different people and filling in the same data again and again. Make sure my contact knows everything about me I’m fed up being told my data is lost in the system or X is on holiday etc etc.. “
INDIVIDUALS’
“They remain faceless and very rarely follow up a visit that has been made”
EXPERIENCE
“I had 2 assessments on consecutive days - asking the same questions and one was while the care worker was here and I was trying to eat my dinner at the same time as answering the questions! But overall I was pleased with the service.”
“More explanation about other options available. Needs were dictated by others not by me - my daughter asked what I wanted and needed, the others told me what I needed.”
“On discharge s/w was meant to ring my daughter but didn't, result of this was that they nearly discharged me into respite care not home as planned.”

4. VOICE OF THE PROFESSIONALS
“I spend half of my time chasing information about patients..”
Community Physiotherapist
“I don’t know who else was working with the patient..”
Community Physiotherapist
“Perfect would be having all information at the point of referral..”
Community Physiotherapist
“Services will refer the patient/user back to the GP in order for a referral to be made into another service.. “
“Should have a joint SC&H and health budget for equipment. Inability to have this leads to another layer of referral in order to access equipment.. “
“Referrals can sometimes be batted around because it does not meet criteria until someone is prepared to pick it up “
“Patients don’t know what each professional does.. “
“We don’t trust each others assessments.. “
VOICE OF THE
“Unable to just have a professional conversation which may resolve the problem, so instead refer.. “
“Bottlenecks accessing services ie; waiting lists – can create delays in patients/users getting the services they need.. “
“Therapists attend patient/user’s homes only to find that a therapist has been the week before.. “
“Multiple folders (representing each service) are left in the patient/users home, shouldn’t there be just one..? “
PROFESSIONALS
“In the allocation process used by SC&H, the patient/user has already been through 2 (poss 3) layers of explaining the issue before or during a visit..if a case has been closed down and they need to access the service again, they have to go through the same process of allocation “
“Should assessments be an ongoing professional assessment of need, rather than individual assessments for each episode of care.. “
“Cross-geographical boundaries can lead to cases being bounced around..confusing the customer and professional “
“Its not clear across professionals who does what..meaning customers may be missing out on services “
“How are the holistic needs of the person assessed..? “

5. CASE STUDY ONE
Colin was a 66 year old gentleman who was diagnosed with motor neurone disease in August He lived at home with his wife and carer H.
There were a large number of professionals involved with Colin following his diagnosis, health, social care and the 3rd sector all played a part in Colin’s story.
Colin and H understood the severity of Colin’s condition and had a desire to make Colin’s remaining time as comfortable as possible whilst maintaining his independence for as long as possible.
As predicted Colin’s condition rapidly deteriorated over a short space of time before he finally passed away in June 2012 shortly after an emergency admission to Stafford Hospital.
This case was studied to understand the issues faced by Colin during his period of working with multiple services.
COLIN

6. Katherine House Hospice
KEY
SSOTP
NON-SSOTP
Organised chaos..
CIS
“Who do I call..?”
“What’s going on with..?”
District Nurse
Multiple Assessments/plans
Referral Central
Telephone directory..
Chase, chase, chase!!!
Duplication of info..
Invisible information..
Delay / Rework
Confusion??
Katherine House Hospice
COLIN
Physiotherapy
“Who’s coming today..?”
ASC
“I thought I told you that before..?”
Social Care Assessor
Social Care OT
“So what happens next..?”
Community OT GP
Wheelchair Services
SALT
Dietician
Respiratory Physio
Dom Care Agencies
Assistive Technology
Social Worker

7. CASE STUDY TWO
Carole is a 91 Year old lady who lives on her own in social housing and does not have any savings. She has two daughters who are supportive of her needs.
Carole was first referred into the DN for her blood pressure due to her mobility issues that restricted her from accessing her local GP, following this visit she was then referred into SC&H over concerns regarding her risk of falls.
In the period March 2012-present Carole has had a number of referrals resulting in cases being open and closed to both health & social care. She was admitted to Russell Hall hospital in January 2013 due to CVA. She returned home in Feb 2013 following a stay in a step-down bed supported by an enablement package.
Carole is currently living at home under a maintenance care package.
This case was studied to understand the issues faced by Carole during her period of working with multiple services.
CAROLE

8. Confused? KEY “I thought I told you that before..?” “Who do I call..?”
SSOTP
NON-SSOTP
“I thought I told you that before..?”
The different professionals involved in Eunice’s care
March 2012 to current day (that we know about!)
District Nurses
“Who do I call..?”
Multiple isolated assessments & plans
Repeating information..
Waiting times
Threshold criteria – NO!!
Invisible info..
Referral central
Chase, Chase, Chase!!
Change the professional (start again..).. GP
CH Duty (CIS)
CAROLE
SG RGN (CIS)
CM Physio (CIS)
JB OT (CIT)
ST Social Worker
(CIS)
SP OT Technician
(CIS)
Prestwood
Nursing Home
Carewatch
(Agency)
Locality Team
ES/NR OT (CIS)
SC Duty (West Team)
JW Physio (CIS)
SJ ISW (CIS)
“What’s going on with..?”
KG Physio (CIS)
AG Duty (CIS)
Russell Hall
Hospital
JN District Nurse
LW Physio Tech (CIS)
KS Physio (CIS)
LM Community
Nurse
Living Independently
Staffordshire Service
“Why can’t you help..?”
Confused?

9. OPERATING PRINCIPLES
We understand the individual, what they want and how they want it
We provide help/support in a way that makes most sense to the individual
We ensure professional transparency, to avoid duplication for both individuals and staff
We work pro-actively to provide the right help, at the right time, by the right person and in the right place
We collectively measure our success based on individuals outcomes and experiences

10. THE OPERATING MODEL LEARN PLAN REVIEW DELIVER
We ensure professional transparency, to avoid duplication for both individuals and staff
We understand the individual, what they want and how they want it
Our support functions are joined up and in line with providing the right help to the individual
LEARN
SIMPLE ACCESS
PLAN
PATIENT/USER-LED
OUTCOME/PREVENTION FOCUSSED
TIMELY
HOLISTIC ASSESSMENT
HOLISTIC CARE PLANNING
We work pro-actively to provide the right help, at the right time, by the right person and in the right place
True joined up commissioning based around the individuals’ needs
PRO-ACTIVE
MULTI-DISCIPLINARY
REVIEW
MEASURE BY OUTCOME
DELIVER
SEAMLESS
PATIENT/USER EXPERIENCE
STATUTORY
EMPOWERED
CO-ORDINATED
LEARNING SYSTEM
RIGHT 4 YOU
We collectively measure our success based on individuals outcomes and experiences
We provide help/support in a way that makes most sense to the individual

11. HOW WOULD THINGS BE DIFFERENT..?
COLIN
Current System..
Applying the new OM..
Multiple referrals & multiple points of contact (had to send a who’s who of all professionals involved along with contact numbers and details of when to contact who at H’s request)
Restricted lines of sight (Professionals not knowing who else is involved - find out who else is working with the patient/user from H ie; OT, information invisible between professionals)
Referring to wrong teams (lack of clarity over what different teams do ie; CIS, GP to wrong physio)
Multiple assessments & plans done in isolation (Individuals repeat information over and over.. Individual plans put in place for different specialism's, new assessments for each episode of care)
Delay (Can’t provide respite until care package in place, can’t arrange care package until equipment provided = DELAYfor continence assessment)
Equipment ordered piecemeal / individual approvals / long delays / frequent chasing – (Colin deteriorating quickly..)
Reactive approach (didn’t order ramp, even though ordered wheelchair)
Each referral treated as a new piece of work (Focus on what I do, not the bigger picture.. open case-treat symptom-close case, no continuity of professional)
Bound by professional boundaries (can’t follow common sense - OT’s referring to other OT’s for certain kit, within a week Colin had visits & assessments from 2xOT’s)
Unable to meet need (no 15 min calls, Double-up’s, visits at required times etc) consequences=more costly support ie; residential, emergency etc
Re-work (ie; paperwork redone as not right 1st time, CHC funding expired as could not source care package quick enough <7days, time limited visits mean run out of time to do things needed, re-book week later)
Single point of contact for everything relating to Colin (Co-ordinator), champion Colin’s care E2E, learn about him and the things that matter to him
Single visible plan, defined overall outcomes that reflect what Colin wants in a way he wants it, everyone working to same plan to increase likelihood of success
Prediction of Colin’s needs over time, single sign-off, devolved decision making to those with whom it makes most sense.
Accountability for delivering outcomes and E2E patient experience shared amongst professionals
Right care, right time, right person Services commissioned/ designed against demand not bound by contractual limitations – Colin gets what he needs.

12. BARRIERS TO INTEGRATION
ACCESS TO INFORMATION
LACK OF UNITED VISION
‘SILO’ WORKING
SEPARATE BUDGETS
ISOLATED COMMISSIONING
GEOGRAPHICAL BOUNDARIES
PERFORMANCE MANAGEMENT
PROFESSIONAL TRUST
NARROW
CARE OPTIONS
CRITERIA
SEPARATE POLICIES
AND PROCEDURES
ACCESS TO INFORMATION
- Difficult, not readily available
- Electronic, paper, in user’s home/not in user’s home
- Poor at the point of referral / lack of visibility of care notes, assessments, care plans etc..
- Cause of duplication/re-work/poor productivity
LACK OF UNITED VISION
‘SILO’ MENTALITY (covers a raft of areas that limit our ability to integrate..)
- Narrow accountability for activity, not holistic and patient/outcome focussed
Decision making / money spending
Individual assessments
BUDGETS
- Separate, driving behaviour on the frontline (I know what you need but I’ll have to refer you to someone else… OT Community/Social etc) (You’re telling me you need to change your care requirements but I’ll have to refer you to someone else.. Health/Social Care)
ISOLATED COMMISSIONING
- Hugely complex commissioning landscape, not aligned (health/social care) on shared vision, budgets & patient user outcomes
GEOGRAPHICAL BOUNDARIES
- Not based on GP registration, can be responsible for only part of the response to demand
PERFORMANCE MANAGEMENT
- Performance is not measured e2e/not patient centred
PROFESSIONAL TRUST
- Professional not trusting others assessments/care plans etc..
????

13. Phase Two Programme Newcastle Stoke Stafford Cannock Seisdon
Work streams
TARGET OPERATING MODEL
Newcastle
Stoke
Stafford
Cannock
Seisdon
East Staffs
Tamworth
Moorlands
Lichfield
Enabling Projects

14. Existing Work Streams and Enablers
Operating Model HR
Performance
Workforce Planning
Organisational Development and Training
Finance
Estates
IT and Information Governance
Professional Leadership
Communications
Enablers
Case Coordination
Standardised Assessments
TBC …..

15. Activity 1
How best can you develop your own local plans in line with the target operating model?
Who will own the local plans?
How should changes be initiated within your own areas?
What will be your process for escalating ideas/barriers that are not within staff’s control?
What types of changes are staff, team leaders, neighbourhood managers and area managers allowed to make without approval from their management?
How would you like to feed ideas and knowledge into the countywide transformation programme?
How will you measure whether your changes are successful whilst ensuring that the customer experience is either improved or not affected by the changes?

16. Activity 1 cont… What we do want
Staff to take ownership for developing an integrated service in line with the target operating model
Changes only to be made within the principles of the target operating model
Staff to engage in corporate plans to remove blockages
A single operating model for the whole service with local variations based on the needs on the individuals in that area
Changes should aim to improve the overall pathway experience of individuals
What we don’t want
28 different models of how we operate that creates a postcode lottery for individuals
Staff and managers working in professional silos
Disengaged staff and managers that are distant from the changes being made

17. Activity 2 What can we do now?
Are there any quick wins that will enable the journey towards integration to begin?
What are the first steps to achieving the target operating model?
Is there anything getting in the way of you making these first steps now?
What messages do you need to take back to your teams from today?