1. Integrated Care: Integrated Community Services for Adults Cath Doman Head of Community Health Commissioning Programme Lead Integrated Care NHS Airedale, Bradford and Leeds Lyn Sowray Assistant Director Adult and Community Services Bradford Metropolitan District Council

2. Integrated care programme Delivering the vision for integration Transformation of health + social care in the District Integration of community services clustered around GP practice/s Services working as a single team for each locality Risk stratification of locality population

3. …whatever the person needs following (or to prevent) acute care or long-term dependence Reablement Rehab Recuperation Return to optimal health + wellbeing In simple terms, it’s…

4. The vision Right care right place first time Joined up services to enable people to regain and keep their optimal health, well- being and independence

5. The health economy Need for new models of care delivery –Funding gap –Shift from hospital to community requires greater capacity and productivity in community services –Growing demand/population requires a preventative approach –Increased capacity to prevent needs escalating –Better case management across partners to reduce bureaucracy, duplication, risk Adapted from slide by Nick Morris BDCT

6. The Partners Commissioners NHS Airedale, Bradford and Leeds Emerging Clinical Commissioning Groups BMDC NYCC (for Craven) Providers Bradford District Care Trust Bradford Teaching Hospitals Airedale NHS FT Bradford Metropolitan Borough Council Voluntary and Community Sector North Yorkshire County Council

7. Integrated functions Community nursing Intermediate care services Community therapy services Long-term conditions management Long-term support and care Rehabilitation and reablement Associated support services - VCS Opportunities to include MH + LD services

8. The programme AccessAssessment, diagnosis + care planning Community beds Home-based supportFalls and bone healthLong-term conditions EstatesITPerformance Assistive technologyVCSCommunications HR + ODFinanceRisk stratification Mental health and dementia Enable

9. Dr Tom Downes 2008

10. Timescale: 2-3 years 2011/12 Transfer + achieve consensus Transfer of community services and development of strategy 2012/13 Change Early wins: test-sites across District of teams working together, common criteria, assessment and records, enablement working alongside therapy and community nursing 2013/14 Polish + make it stick 111, pooled budged, single management, health + social care services delivered from community-based hubs Practices putting in proposals now

11. Introducing Mrs Jones… Distric t nurse GP OT podiatrist Out- patient s Social worke r Social service s OT Physi o Practic e nurse Home care Heart doc Diabetes doc Warde n BDCTBMDCInCommunitiesBTHFTVCSANHSFTGP Discharge team Equipmen t services CMHT Housing grants MATS Communit y Matron

12. Discussion and questions