Integrated Locality Care Teams Improving outcomes for individuals - - PowerPoint PPT Presentation

Integrated Locality Care Teams

Improving outcomes for individuals through integrated care

“Better Together”

Strategic Drivers

• National policy
• Fit for the Future Programme
• Quality Innovation Productivity Prevention
• Local vision – ‘Model of Care’
• Improved outcomes
• LTC Model; Risk Profiling, Neighbourhood

Care Teams, Self Care/Shared Decision Making

Case for Change

• Access points can be confusing for local people
• Silo working
• Duplication
• Need to build better relationships between

professionals

• Fragmentation
• Resource Utilisation
• Most vulnerable patients fall between the gaps

The Solution

• A pro-active case management model
• Locality based multi-disciplinary team

approach

• Person at the centre – to maximise the

efficiencies and effectiveness of resources

• Core Team links to other co-ordinated locality

services

• Services and care – right first time, every time

Key Principles

Individual

Personal Care Plan EDD or Review Date One trusted generic assessment Access to service based on need Prompt treatment & care Outcome focused Communication MDT review Quality Governance Satisfaction Safety Known to all Case based discussions Case Management

Objectives

• To exploit the potential gains of integration across health and social care
• To develop a performance dashboard that monitors the impact of the ILCTs
• To fully deploy/implement the agreed model of care following evaluation of the

Early Implementer sites.

• Delivery of the agreed pathway of care to ensure seamless, risk managed care,

with reduced duplication of assessment, diagnostics and the sharing of information.

• Provision of a fully skilled multi-disciplinary community team to ensure staff have

the required knowledge and skills to deliver safe and effective care, in the context

• f evidence based practice.
• Reduce unnecessary admissions to hospital of patients in crisis, who could be

safely looked after at home with support.

• Increase the timely discharge of patients from hospital who no longer require

acute medical intervention.

• Work towards developing the capability to share patient level data with GP

Practices and Social Services via a single IT system, using a collaborative approach with the Local Authority.

Key Actions to Date

April 2011

• CCG Approval to concept of Integrated Local Care Teams
• Practice Questionnaire re: Community Nursing

May 2011

• Project meetings commenced
• Final CSED LTC Event hosted by JCU – Production of 23 proposals

June 2011

• Project Plan finalised
• Agreement of Locality population sizes

July 2011

• LHE Workshop
• Appointed 4 Early Implementer Localities across North Staffordshire &

Stoke on Trent August 2011

• Steering Group refreshed
• Draft objectives, key principles and patient flow completed
• 6 Places awarded on the Integrated Development Programme (IDP)

through Birmingham University September 2011

• IDP University sessions commenced
• 1st Early Implementer meeting with Tunstall Locality

October 2011

• 1st Early Implementer meeting with Leek & Biddulph Locality
• 1st Early Implementer meeting with Newcastle South Locality
• 1st Draft of service specification
• 1st Early Implementer meeting with Longton Locality

November 2011

• 1st Early Implementer workshop with Newcastle South Locality
• All Early Implementer practices signed up to and able to use the Risk

Stratification Tool

• Business Planning session
• LHE Commissioning Summit

December 2011

• 1st Draft Business Case submitted as part of IDP
• 1st Operational Level Meeting with Newcastle South Locality
• Data Sharing Agreement approved

Next Steps

• Refining the Business Case
• Milestone review to maintain momentum
• Baseline & Impact Modelling
• Presentation to organisational boards
• Political approval
• Continued staff and user engagement
• Implementation of Business Case
• Service Evaluation post implementation