Chief Allied Health Professions Officer’s Conference 2016 Workshop 3: Integrated Care – Chair Lindsey Hughes iCares – population based delivery of care. Ruth Williams, Clinical Directorate Lead, Community and Therapies Clinical Group. Sandwell and West Birmingham Hospitals NHS Trust.

1. @icares_SWBH
Integrated Care Services
(iCares)

2. • Long term conditions / adults
• Case management is everyone’s business
• Community Rehabilitation is everyone’s business
 Open access for life
 Respond according to patients clinical need irrespective
of diagnosis or location
 3 hours – admission avoidance
 72 hours – care management
 <15 days – rehabilitation / reablement
 Self care & self management
iCares - 7 days a week, 8am – 8pm

3. Case for Change - The challenge
Cost saving every year
60% increase in demand (DH QIPP)
Demand increasingly complex
Customer satisfaction (client &
commissioner)
Quality & Safety
•Numerous Teams
•5 points of access
•8+ bases for staff
•Long waits
•Handoffs & inter-team
referrals
•Variation across bases
•Duplication
•Part time admin & answer
machines in each base
•Mostly 5 days a week
•Lots of paper & filing
cabinets

4. QIPP LTC: Sir John Oldham, clinical lead
• 3 part approach to managing increase in demand
– Risk stratification
– Integrated locality teams
– Self care
Need to implement all 3 together and systematically
The solution?

5. The Evidence Base
An integrated locality care
team embraces specialist
services when necessary,
but treats a patient
holistically, regardless of
their condition(s).
Thus moving from a
biomedical model to a
psycho-social medical
model (QIPP Handbook).

6. Developing the pathway
• Audits of
– Public health data – incidence and prevalence
– Telephone calls
– Triage processes
– Appointment slots offered vs. planned
– Capacity modelling
– DNA / missed appointments
– Response Times
– WTE, skill mix, bases
• Review of evidence base
• A high level idea: no detail
• Met with GPs, managers, union reps, PCT

7. Engagement
• Listening into Action event (LiA)
• Function before form
• Working parties
• Pathway development
• Scoping & borrowing /
Benchmarking
• Market place event
• Options appraisal re form
• Process development

8. How did we ensure engagement
UPWARDS, ACROSS AND DOWN
• Conscious communication
 Emotional
 Theoretical / Analytical
 Policy & Process Driven
• Varied communication styles
 Tell stories
 Newsletters, emails
 Be visible, open door, walk the walk
• Shared the context, the data & the patient voice
 Unions / Leaders / Commissioners / GPs / The staff (via LiA) / Patients
• Honesty & openness. We are not perfect, its OK to say sorry.
• Asked (expected) staff to perform – they will, they know the solutions & are more
creative
• Fed back praise & recognition
• Celebrated the successes & acknowledged the issues
• Focused on the patient outcomes & impact.
• Never gave up

9. Consultation
• Formal management of
change
• Unions welcomed
• Open door
• Leadership skills
• No name yet
• Start date – no going back
• Everyone changed role,
base, line manager, hours of
work

10. Decision
Contact
CentreTriage
Urgent
Specialist
Routine
Self Management
Its simple

11. It’s joined up Urgent
• We will see you urgently to stop your condition
getting worse and where it is safe to avoid an
admission to hospital
Specialist
• We will help you to see a specialist to work with
you to;
• understand your condition
• manage your condition better
• get treatment for your condition
Routine
• We will provide treatment to help you get better
and live life as well as possible
Self-Care
• We will help you to understand your condition
and what you can do to help yourself

12. Services / functions delivered by iCares
Rapid Response Doms
AA Clinic / PCAT
OPAT
DVT
OBI / IMC
Care Management
CNSs
Care Homes team
Specialists within locality teams
Bridging the Gap
Community Offer
Prevention
Reablement
Rehabilitation incl. stroke,
falls, neuro, TBI, frailty
Palliative Rehab
Rehab Unit (DH)

13. Workforce - Headcount
Registered Staff 73 74%
Non Registered
Staff
26 26%
Therapists 43 59%
Nurses 30 41%
Delivered by
Community Matrons, Clinical Nurse Specialists
Therapists – PT / OT / SLT
Psychologists
Assistant Practitioners, Support Workers, Home Accident Prevention Team
Admin hubs
Clinical Team Leaders

14. Responsiveness
 Wait for rehab and reablement dropped from 40 days to an average of 16 days
 Bed occupancy has increased from 85% - 93%
 LOS in Own Bed Instead 24 days (standard 29 days)
 92% of patients return home from nursing home based IMC beds in under 6
weeks
 2% reduction in readmissions via LACE
Patient experience
 93% of patients would recommend the service to their friends and family
 77% of patient set rehab goals are achieved with 100% success
(90% full and part achieved)
 93% of AA Doms referrals avoid admission to acute
Outputs / KPIs

15. Staff tell us……
“Autonomous working”
“Variety of caseload in community”
“Holistic working”
“Give them (patients) our all”
“Opinions are valued”
“Leaders seem to care”
Staff satisfaction survey – 92% of staff report in
the Trust’s Your Voice survey that they feel involved
and motivated at work

16. Users tell us………
“You hear about going the extra mile,
they went an extra 200 miles”
“Don’t know where we would be
without you”
“Every goal I wanted to achieve I
achieved”
“Pat yourselves on the back, you are
the best thing that ever happened to
me”
“Like family walking through the
door”

17. Sustaining the change
Workforce are the key to momentum
• Co-location
• No professional leads
• Permission to find solutions
– Do what’s right for the patient
• Specialists vs. generalists debate
• Tenacity
• Resilience

18. • Focus on outcomes & commissioning
• Use the evidence base
• Cant communicate too much
• Ask for help
• The teams know the answers
• Tolerance of difference
• There is nothing to hide
• The theorists need to know why
• The reflectors need to reflect
• The power of the data & patient stories
to keep the momentum going
Learning

19. • The ability to respond according to clinical need rather
than location, age or diagnosis
• The breadth of its reach - from pre-diagnosis to death
• Depth of expertise held by co-located nurses, therapists &
other professionals who together are able to do what’s
right for the patient
• Case Management is everyone’s business
• Community Rehabilitation is everyone’s business
Why do we think it works?

20. sandwell.icares@nhs.net
ruth.williams2@nhs.net
0121 507 2664 (option 5)
@icares_SWBH
Thank You