1. Resources, learning and growth (What we need to enhance to succeed) Outcomes (What we want to achieve) Internal Processes (What we need to do well to reach our goals) Customers (What we need to do for and with others) People over 65 Developing workforce strategies including maintaining multi- disciplinary and multi- agency teams Avoid inappropriate admissions to hospital Longer, healthier, independent lives Avoid inappropriate admissions to long term care (institutions) Carers Provide the right support to enable carers to care Safe, timely and integrated transfer of care planning from hospital and other settings Provide citizens with a choice, voice and control over the care they receive. Care for older people at home when possible and appropriate Better Management Information Systems Delivery Commissioning Managing to our budgets (interdependency) Investment in improved pathways for older people (invest to save/’pump priming’ Aligning budget and financial cycles High level sponsorship and culture change Assess needs effectively (Joint SNA) Develop commissioning plans that address priorities Ensure the quality of delivery through monitoring Integrated individual assessment Provide appropriate intervention at the right time Rehabilitate effectively to maximise independence Review to ensure care packages are still appropriate 1.Required changes in workforce clearly defined 1.Joint governance arrangements established 2.Chief Officers signed up to joint changes 1.Spend vs.. profiled budget for social, care (admission to LTC, Nursing H homes, IC) 2.Cost of admission to acute hospitals 3.Cost of excess bed days 4.Admission into NHS continuing care 5.Cost of home care 1.Long term goal: One integrated system to manage the case file 2.Short term proxy: Sharing of information between stakeholders 1.% of budget ‘pooled' with other organisations – section 31 2.Agreed joint financial governance arrangements 1.Additional funding secured 2.Resources redeployed 1.Jointly agreed SNA in place (City, City, County, County). 1.All commissioning intentions jointly agreed 1.% of people with complex needs who have a personalised health and social care plan. 2.% of carers who receive an assessment. 1.% of standards for better health met. 2.% of standards for better care met. 3.Numbers of complaints about care standards 4.Incident reporting. 1.Access to rehabilitation (developmental measure) 2.Dependency rates on discharge 1.% of older people in the borough accessing services. (shows effectiveness of the SNA) 2.Waiting times for social care and health services (aggregate) 1.Delayed transfers of care 1.% of people who receive a care package which includes periodic review 1.Take up of self-directed support 2.Periodic joint surveys of older people in receipt of care and satisfaction level over their input to their care. 1.% of people discharged from hospital who are readmitted within 28 days. 2.Reduction in emergency admissions 3.Admissions to ‘step up’ facilities (developmental) 1.Intensive home care provided to older adults. 2.No. of patients with complex needs who have a named case manager/care co- ordinator. 1.Number of older people admitted to long term care (institutions) without first going to intermediate care 2.Number of older people admitted to long term care without first receiving comprehensive geriatric assessment 1.% of carers receiving a service following assessment or review. 1.Reduction in the inequality of life span 2. Reduction in chronic disease – heart, diabetes, COPD 3.People in long term care (C72) vs people living in their own home (C32) 4.Take up of benefits Nottinghamshire health and social care economy draft strategy map Keep patients in care for the right length of time 1.Average length of stay