Integrated/Co-located
Anticipatory Support Services for
Older People
Tim Eltringham
Head of Health and Community Care
East...
Outline
• Background
• Where we started
• Problems
• Redesign Process
• Reshaping Care
• Alignment to GPs
• Implementation...
East Renfrewshire
• South of
Glasgow
• 90,000 people
• Relatively
affluent
• Highest
proportion of
people over 65 in
NHSGGC
CHCP
• Single Committee
• Single Director
accountable to 2 CEs
• Managing all SW and
NHS Community
services
• Integrated M...
Teams involved in Redesign
Older People and Physical Disability
• 3 NHS Rehab Teams
• 5 Social work teams
• 2 Occupational...
Where we started
Hospital
SW Duty
SW
OT
Rehab
OT Duty
GP
Public
Problems we saw
• Numerous ways into service
• Spreadsheets/books/multiple recording
• Handovers
• Duplication of informat...
Emerging thinking
• Existing arrangements not working
• Long Term Conditions and Social Work
• GPs as the universal servic...
The Redesign Process
• Time, Time, Time
• Clarity of Purpose:
Outcomes
• Process Culture
• Staff engagement
• Staff side
e...
Issues we worked on
• Development of the Management Structure
• Alignment of Rehab Staff
• Processes to manage referrals/d...
Governance
• Different professions have different
requirements
• Social Work Delegated Authority
• NHS Autonomous Practice
New Structure
RES Manager
Levern Valley
Service Manager
Eastwood 1
Service Manager
Eastwood 2
Service Manager
Team Manager...
Systems
• Go Live September 2013
• Single Point of Access
• SCI referrals from GPs
• MDT Action Team triage referrals
• At...
Performance Improvement
• Not target driven
• Measures are to
improve performance
• Measures Board in
development
- Admiss...
Anticipatory Care Planning
• Investment in Advanced Nurse
Practitioners
• “Anticipatory Care is everyone’s
business”
• Pat...
Outstanding Issues
• Data sharing
• Consent
• Improving integration with OAMHT
• Getting time to work pro-actively with
GP...
Is it working?
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Integrated/Co-located Anticipatory Support Services For Older People E25

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Session from managers and front line staff about how to develop such a service, what its impact has been on improving outcomes for older people, the importance of GP practice participation, what the organisational/delivery challenges are and how differences in professional governance and statutory functions have been addressed. Contributed by: East Renfrewshire CHCP

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Integrated/Co-located Anticipatory Support Services For Older People E25

  1. 1. Integrated/Co-located Anticipatory Support Services for Older People Tim Eltringham Head of Health and Community Care East Renfrewshire CHCP
  2. 2. Outline • Background • Where we started • Problems • Redesign Process • Reshaping Care • Alignment to GPs • Implementation • Outstanding Issues
  3. 3. East Renfrewshire • South of Glasgow • 90,000 people • Relatively affluent • Highest proportion of people over 65 in NHSGGC
  4. 4. CHCP • Single Committee • Single Director accountable to 2 CEs • Managing all SW and NHS Community services • Integrated Management Team • CSWO at Head of Service level
  5. 5. Teams involved in Redesign Older People and Physical Disability • 3 NHS Rehab Teams • 5 Social work teams • 2 Occupational Therapy Teams • District Nursing Service • OAMH for part of the area
  6. 6. Where we started Hospital SW Duty SW OT Rehab OT Duty GP Public
  7. 7. Problems we saw • Numerous ways into service • Spreadsheets/books/multiple recording • Handovers • Duplication of information • Numerous contacts with service users • Checking • Progress chasing • IT system issues
  8. 8. Emerging thinking • Existing arrangements not working • Long Term Conditions and Social Work • GPs as the universal service • Engagement with practices • Pilot work with GP team meetings
  9. 9. The Redesign Process • Time, Time, Time • Clarity of Purpose: Outcomes • Process Culture • Staff engagement • Staff side engagement
  10. 10. Issues we worked on • Development of the Management Structure • Alignment of Rehab Staff • Processes to manage referrals/demand (inc Duty) • Professional leadership • Administration Support • Accommodation • Linkage with hospitals • Process for transition including scenario planning • Staff Briefings • Team building pre and post implementation
  11. 11. Governance • Different professions have different requirements • Social Work Delegated Authority • NHS Autonomous Practice
  12. 12. New Structure RES Manager Levern Valley Service Manager Eastwood 1 Service Manager Eastwood 2 Service Manager Team Manager Team Manager Team Manager Team Manager Team Manager Team Manager Team Manager Team ManagerNote: OAMH Function District NursingDistrict Nursing District Nursing Jewish Care
  13. 13. Systems • Go Live September 2013 • Single Point of Access • SCI referrals from GPs • MDT Action Team triage referrals • Attendance at GP Meetings • Community-based Geriatrician meetings
  14. 14. Performance Improvement • Not target driven • Measures are to improve performance • Measures Board in development - Admission rates - Delayed Discharges - Throughput - Outcomes
  15. 15. Anticipatory Care Planning • Investment in Advanced Nurse Practitioners • “Anticipatory Care is everyone’s business” • Pathways and paperwork in development • Integrated learning approach being adopted
  16. 16. Outstanding Issues • Data sharing • Consent • Improving integration with OAMHT • Getting time to work pro-actively with GPs • Alignment of ACP work by teams and GPs
  17. 17. Is it working?

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