1. Rural Generic Support Worker Opportunities and Synergies Dr Anne Hendry National Clinical Lead for Integrated Care Joint Improvement Team

2. Reshaping Care for Older People >10 Year Programme to 2021 >£ 300 million Change Fund >32 Partnerships between NHS: primary, acute, mental health LA: social care & housing Third and Independent sectors Older people and carers >Change Plans signed off by all partners >Joint Commissioning Plan >Improvement Network

3. 2020 Vision Everyone is able to live longer healthier lives at home, or in a homely setting. > Integrated health and social care, a focus on prevention, anticipation and supported self management. > When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. > Care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. > There will be a focus on ensuring that people get back to their home or community as soon as appropriate, with minimal risk of re-admission.

4. Policy Alignment

5. Secondary Care / Acute Primary Care State- funded social care Carers & support to carers Universal services, family, friends, community Support, information and training to carers Resource shift, over time, from crisis management and critical intervensions to prevention & “low level” support Self-directed support – choice/control for citizens Person-centred health care / self- management Self-directed Support: in context Other “crisis” interventions: Homelessness Criminal prosecution Dealing with drug/alcohol addiction Focus on quality, build on people’s assets, professionals and citizens work collaboratively Building the capacity of communities

6. Person Centred Care Primary Care: Long term conditions care planning Community Care Intermediate care: Rehab and enablement at home / care settings Care management/ anticipatory care: Community nursing Mental Health: Recovery support NHS Self-Management Support: Self-management programmes/ psychological interventions

7. Integration:Purpose >To deliver nationally agreed outcomes for health and wellbeing >To improve the quality and consistency of care for patients, carers, service users and their families >To provide seamless, joined up care that enables people to stay in their homes, or another homely setting, where it is safe for them to do so >To ensure that resources are used effectively and efficiently to deliver services that meet the needs of the growing population of people with longer term and often complex needs

8. There are more people in Scotland with multimorbidity below 65 years than above

9. Public Bodies (Joint Working) Scotland Bill >Royal Assent for legislation anticipated April 2014 >Transition / shadow arrangements ongoing >Integration Plan (Scheme) >OD and workforce plans – transition funding £7 M for 2014/15 >Integration Authorities from April 2015 >Jointly appointed chief officer >Integrated budgets for community health and social care and some acute hospital services >Strategic commissioning plan >Locality planning >Public and professional engagement

10. Integrated Care - Local and Personal

11. Technology Enabled Integrated Community Team

12. Intermediate Care >Integrated and enabling services at times of transition >Alternatives to admission, early supported discharge and support to regain independence Time limited >Hospital at Home – defined specialist led service >Home based Rapid Response / Early Supported Discharge services >Bed Based - Step Up/Step Down beds in care home / community hospital >Reablement – service / approach Chronic Care >Integrated Community Support Team >Community Ward

13. http://www.knowledge.scot.nhs.uk/chin

16. Community Services programme

17. Change Fund