2. Stockport Together – Neighbourhoods -Stockport Together context -Proactive Care programme -Neighbourhoods

3. Introductions Dr Ash Patel Viaduct Dr Viren Mehta Roger Roberts

4. Four programmes Proactive Care: Supporting people with long-term health conditions or social care needs to remain in their preferred location. Improving access to support and increasing the quality of care for people. Helping individuals to avoid the need for urgent (same-day) health or social care - e.g. reducing A&E admissions. Prevention and Empowerment: Supporting people in taking steps to improve their own well-being. Increasing the number of people who understand their own health and social care needs. Reduce people’s need to rely on health and social care services. Planned Care: Working with people who have a known need and require on-going access to services. Reducing unnecessary outpatient attendances and GP referrals by working to better understand patient needs. Maximising the use of technology to improve patient experience. Urgent Care: Providing access to people needing urgent, same-day care. Improving the way people who require urgent access to care are assessed, stabilised and discharged. Helping to stabilise people as soon as possible and to improve their experience and outcomes.

5. Five components

6. Specialist Response PL4. Zone 4- Specialist services including urgent access to planned care Optimising health and well-being PRE1. Population - Identifying risks and empowering change PRO1.1. Finding people early PRO1.2. Prevention where there is a known need PL1. ZONE 1: Self help advice PRE5. Wider determinants of health Primary Response PL2. Zone 2- Primary care services PL3. Zone 3- Primary care with specialist advice PRO3.1. Support to people with LTCs UC3.2. Non-Urgent Care Hub PRE4. Services – Prevention embedded in every pathway supported by IT Urgent Stabilisation Response PRO4.1. Crisis response UC1. Single point of access (SPA) and virtual admission assessment UC2. Initial assessment service (face-to-face) UC3.1. Urgent Care Hub PRO3.3. Strategic design of Neighbourhood Teams PRO3.4. Intermediate Tier redesign PRO3.4. Strategic design of Locality Teams PRO3.2. Complex Care PRO4.2. Recovery response UC3.3. Integrated discharge teams Proactive Response Design Components 6

7. Proactive care principles People proactively identified One person manages/coordinates One care plan Using one record Person centred No plan concerning me without me Person empowered to Self Care Supported by an empowered community Support 7 days a week Care provided proactively to reduce crisis Care managed as a team with no referrals People found early

8. Background – Neighbourhood Service Vanguard Delivering to neighbourhoods of circa 30 – 50k GP registered populations 8 neighbourhoods across borough Neighbourhood Service delivered by: GP groups– GPs nurses and practice staff Integrated Neighbourhood Team – nursing, social care, Aligned third sector, Pharmacists Mental health services and alignment TBC Allied health professionals, Business support Intermediate Tier services

9. Flexible team Federated GP Vehicle GP Practice MDT Streamlined referral Clinical risk and accountability Service delivery Integrated Neighbourhood Team (x8 teams) Structure of Integrated neighbourhood Service—Early Adopter Cheadle and Bramhall, October 15 Multidisciplinary Neighbourhood Team Manager Band 7/MB4 Social Workers SO2 Social Care Officers SC5/6 Health Assistant Practitioner Band 4 Business Support Health Care Assistant Band 3 District Nurses Band 6 Social Care ATM SO3 Registered Nurses Band 5 Targeted Prevention Alliance Advanced nurse practitioner clinical lead facilitator Medicines Management Mental Health (TBC) REaCH Unregistered Health Care Staff OTs SO2 Joint care planning case finding Information sharing

10. Integrated Neighbourhood Teams 8 x integrated multi-disciplinary Neighbourhood Teams –Circa 30 staff including nursing, social care, allied health professionals, business support Multi disciplinary line management Co-location Information-sharing agreements Information technology Relationship-building with broader partners in local area Workforce development to build skills and team identity

11. Finalise scope, model & funding Operational co- design of neighbourhood team model Go live: Early Adopters. Extended operating hours, proactive model, shared functions, neighbourhood service JuneJulyAugSeptOctApril 20152016 Go live: pan- borough co-located multi-disciplinary Neighbourhood Teams Phase 1 Enabler Implementation – Accommodation, IM&T, Communication, Workforce Development, HR Go live cross borough - full model Co- design of local approaches and systems Phase 2 Enabler Implementation – IM&T, Communication, Workforce Development, HR Neighbourhood Service Roll Out Timeline Respond to wider Proactive work to deliver at neighbourhood and locality level – extend scope, model, and funding allocation GP Practice co- design of federated model Go live: GP federated model in Cheadle and Bramhall Targeted Prevention Alliance go live and design

12. Neighbourhood Teams Implementation For October 2015, 3 levels of implementation: 1.Early Adopter - Cheadle and Bramhall – aligning the Neighbourhood Team to the Federated GP Vehicle 2.Early Adopter - Marple and Werneth - aligning the Neighbourhood Team to separate GP Practices 3.Integrated, co-located Neighbourhood Teams operating across Stockport

13. Neighbourhood Approach

14. Work streams 1.Establishment of core neighbourhood teams 2.Review of other services three phases –borough wide services –To join the core team 3.Intermediate tier service review options in August 4.Care homes realignment and support – in progress 5.Targeted prevention - new service started July

15. Development phases Core team GPs, DNs, SWs Core team Plus 3 rd sector Core team Plus 3 rd sector Mental Health Core team Plus 3 rd sector, Mental Health, Therapy, Intermediate tier Full new Out of hospital service with prevention, planned and urgent links Plan Do Study Act Plan Do Study Act Plan Do Study Act Plan Do Study Act Plan Do Study Act

16. Early Adopter: Proactive Model

17. Key Deliverables Proactive case identification and management Multi-disciplinary triage offer delivered at neighbourhood level Aim for no formal referrals within Neighbourhood Service Holistic, joint assessments for care and support planning, with specialist assessments added where required: –Motivational and promote resilience and self-reliance –Incorporate contingency for deterioration –Make best use of wider community and innovative solutions Case co-ordination delivered by all team disciplines

18. Key Deliverables cont.. Extended operating hours to cover evenings and weekends Systems to enable joint working with wider partners on most complex cases Community management of deterioration and response to crisis, where possible Rapid access to specialist services for assessment and intervention when needed Clear pathways between urgent care and neighbourhood service

19. Key challenges Cultural change – shift from reactive to proactive, silos to collaboration Estates to enable co-location IM&T including network access and information sharing Operational capacity to participate in co-design and change process GPs working closer together, and associated indemnity Workforce

20. Way from here 5 more meetings Practices working together Seven day working Identification and management of complex people Management of acute on the day activity How do we find and start treatment early There is NO master plan it is up to us how and what this looks like

21. Proactive Care and Support Good Access to advice on general & health issues Coordinated care when needed Shared Expertise across practices Delivery of high quality care Children That is up to us