1. Care Closer to Home Working with the voluntary sector
Optimising health and independence

2. Contents Introduction and vision Drivers for change
Outcomes to be achieved
Working with the Voluntary Sector

3. Introduction and vision for CC2H
Principles:
Patient Centred, empowerment and support for self-management
Joined up care
Case Management
The right level of care – shift to out-of-hospital settings
Recovery focus
Prevention is better than cure
Fundamentals of the contract:
7 year contract worth £237m from April 2016
Delivered £2M cost savings
Wrapped around Primary Care
Deeper integration with Acute, Mental Health, social care partners
1% ring-fenced for the voluntary sector

4. Drivers for change The system is not sustainable
The resident population of North East Essex is expected between to rise by 13%. This is an older population with increasing prevalence of frailty and multiple long term conditions.
This group of patients accounts for:
Nearly 70% of health & social care spend
Nearly 80% of in patient bed days
55% of GP appointments
Nearly 70% of outpatient and A&E attendances
80% of people over 80 have one long term condition, 40% have 2 or more.
This means there are huge overlaps in services and we can’t afford to continue to fund this.
Proportion of people with long term conditions by Age
% with one of more LTC

5. Transformation over the lifetime of the contract
ACE’s role:
system integrator
Delivered through Integrated Care Teams
Patient owned care
Leading a range of providers to deliver coordinated community care
Organising around the practice to provide a seamless service to patients
Supporting patients to take more responsibility for their health and wellbeing

6. The Care Pathway * Larger version included in packs. *
(left hand side)
CCG Consultation.
Listened to patients and referrers
Listening exercises
Meetings with referrers
Patient panels
(right hand side)
We designed the model to deliver.

7. Outcomes to be achieved by CC2H
Helping people be independent and improving patient and carer outcomes
Helping our local community to be healthier
Building a network of integrated services
Maximising system resilience & sustainability
Innovation driving quality and value for money
Helping people be independent and improving patient and carer outcomes:
Putting patients at the centre – self care
Developing care and support plans – owned by the patient
All patients with complex needs will have a care co-ordinator
Helping our local community to be healthier:
Focusing on prevention and early intervention
We know the local communities
Building a network of integrated services:
We will build on local partnerships and establish new ones to drive integrations through co-development of care pathway.
Removing complexity
Community Gateway, referral, assessment
Maximising system resilience & sustainability
Committed to and focussed on North East Essex
Working with the supply chain
More services within the contract
Social Enterprise – investing back
Innovation driving quality and value for money
Model based on best practice from around the UK and beyond
Use of technology
Learning from others
Innovative workforce
Support to self-care
To support clinical care
Over the life of the contract move from Provider to System Integrator.
Contract 7 years

8. But this can’t be achieved by ACE alone
Need to work in much closer partnership with the voluntary sector
Design solutions together – weave these effectively into our services
Share information – communicate regularly at all levels
Develop a 7 year strategy – won’t achieve everything over night

9. Next Steps
Developing a longer term strategy with Colchester and Tendring CVS
Starting with 2 key priorities:
Self-management
Promoting independence
More details available in the Care Closer to Home Workshop