The document provides an overview of integrated health and social care in North Kent, including: 1) It discusses the complexities of the current health and social care system in Kent and past pilots using telehealth and telecare that demonstrated benefits like reduced admissions and costs. 2) It outlines the current agenda around the Pioneer Programme and Better Care Fund aimed at integrating services. 3) North Kent's approach focuses on transforming services to promote independence, provide the right care in the right place, and deliver seamless integrated care for those with complex needs through measures like shared care plans and integrated primary care teams.

1. Alison Davis
Director Integrated Care, North Kent
17th June 14
Integrated Health & Social Care: service
transformation supported by technology

2. • Brief Introduction to the complexities of the
Health and Social Care system in Kent
• History of use of telehealth/telecare ,whole
system demonstrator and what we learned
• Current agenda including pioneer programme
and Better Care Fund (BCF)
• North Kent approach to the Integration of
Health and Social Care
Content

3. Kent & Medway
Location
Sea on 3 sides,
London suburbs
Mixture of Affluent, Rural and very deprived areas
across the County.
Health and
social care structure
8 CCGs, 1 county council, 12 borough councils, 1
unitary authority, 4 acute hospital trusts
Demographics
• Total Population: 1.7m
• Mixture of Affluent, Rural and very deprived areas
across the County.
• Better health outcomes when compared to
England
• Variation at local level with Dartford, Dover, Swale
and Thanet have higher all cause mortality rates.
• Increasing elderly population
• Age 65+ predicted to grow by 9.7% between 2012
and 2016
• 17.3% of the population are aged 65+
• Within the target population, individuals report
having an average of 1.6 of the three target
conditions of HF, COPD, Diabetes

4. Advanced Assistive Technology in Kent
2004 The Kent Telecare Pilot
1100 users of enhanced Telecare Packages
93% felt more independent
93% also felt safer in their own homes
Reduction in residential placements
2005 The Kent Telehealth Pilot
One of the first in the UK to formally evaluate AAT and the benefits to the Health economy
Reduction in A&E Attendances
Reduction in unplanned Admissions
£1800 average saving per patient over 6 months
2008 -2011 WSD (Telecare & Telehealth)
Largest Randomised Control Trial in the World 6000 participants
December 11
20% reduction unplanned admissions
15% reduction in A&E attendances
14% reduction in bed days
45% reduction in mortality rates.
June 12
Telehealth reduces Hospital Admissions but unlikely to have a significant effect on costs.
Feb 13
Telehealth did not improve quality of life
Telecare has no significant impact on the use of other NHS or social care services

5. • A better quality of care, lower mortality rates and
reduced unplanned hospital admissions are possible
• Patients on the whole like this type of intervention and
age is no barrier
• Deploying appropriate technology at the appropriate time
to the appropriate patient
• Eligibility criteria and critical mass-technology alone does
not bring the change – you need service transformation
• Clinicians key to implementation and success
• Education and training – skilled competent workforce
• Need to Identify an appropriate procurement model to
realise cost benefits
What did we learn?

6. • NHS - over 1 million patient contacts every 36 hours
• Increase in Long Term Condition – 1:3 people with a Long
Term Condition
• In England over 15 m people have a long term condition with
numbers set to increase in the next 5 to 10 years, especially
co-morbidity
• People with long term conditions use 72% of inpatient beds,
68% of out-patient appointments and 55% of GP
appointments
• Treatment and care of those with LTCs account for 70% of
the total health and social care spend in England, or almost
£7 in every £10 spent
• Deliver more for less – increasing demand and financial
challenge
The Challenge

7. I want…….
…less time in hospital
…independence
…empowerment
…own bed
…prevention of exacerbation
…in control
…freedom
…more time
…understand
own condition
…fewer trips to
see specialist

8. North Kent Vision
“Transformation of the Health & social care system so that
it works better for people, with a focus on promoting
independence and self care, delivering the right care, right
time, right place, providing seamless, integrated care for
people, particularly those with complex needs”
• Better access
• Increased independence
• More control
• Improved care at home
• Live and die safely at home
• Shared care plans

9. “A single pooled budget for health and social care services
to work more closely together in local areas, based on a
plan agreed between the NHS and local authorities”
6 National conditions
• Plans to be jointly agreed
• Protection for social care services (not spending)
• 7 day services in health and social care
• Better data sharing between health and social care
based on the NHS number
• Assure joint approach to assessments and care planning,
where funding is used for integrated packages of care
there will be an accountable professional
• Agreement on the consequential impact of changes in
the acute sector
Better Care Fund (BCF)

10. The Integrated Care & Support Pioneer
Programme
• 14 areas selected to lead on health
and social care integration.
• Support from the Department of
Health and 40 national partners.
• Responsibility to “barrier bust”.
• Underpinned by the Better Care
Fund.

11. Integrated Transformation Components
Non Acute bed Provision: Consultant
and GP support; Integrated Care
Centres; Extra Care; Rehab Units;
Community Hospital beds; Private
Residential and Nursing bed provision
Crisis Response Services: Access to
Shared Anticipatory Care Plans by the
ambulance service, enhanced rapid
response ,enablement services and
voluntary sector based crisis response
services.
Integrated Care Home support:
Integrated teams including
Consultant and GP support; Use of
technology to Care Homes / Extra
Care Housing providers.
Integrated Equipment , DFGs, capital
adaptations & assistive technologies
at the front end of all the services
video conferencing with clinicians
and development of new pathways.
Improved data sharing
Promotion of the NHS umber, better
health information, use of the health &
social care information centre, patients
accessing own health records. GPs
linked to hospital data.
Operating model:
Integrated skill mix, assessors
accessing integrated care direct: i.e.
nurses accessing social care and
case managers nursing care, skills for
mental health, dementia/LD
a
Integrated Primary Care Teams 24/7
access to multi-disciplinary teams
coordinated by the GP, inc mental
health/dementia; risk stratifying
patients; access to one shared care
plan for patient and professionals
Integrated Access:
Integrated Locality Referral Unit;
7 days a week direct access and 24/7
crisis response ; Access to one shared
care plan on an integrated platform.
Integrated Discharge Teams: Across
acute & community; 7 days a week
working including Rapid Response;
Enablement” Going Home Teams”
“I can plan my care
with people who
work together to
understand me and
my carer(s), allow
me control, and
bring together
services to achieve
the outcomes
important to me.”

12. The Future of Health & Social Care
By 2015
• Integrated health and social care teams working 7 days, 24/7 in your
local community.
• Your GP as the coordinator of your care, bridging the gap between
your GP, social care, community health services and your hospital.
Supported by the community and voluntary sector.
• You will have access to a shared care plan so you and everyone
around you know about your care and support.
• Access services through a local referral unit with access to crisis
teams and rapid response .
By 2016:
• Hospitals without walls.
• One team, one estate working towards one budget.
• The continued focus on enablement, admission avoidance and crisis
intervention.

13. New Model of Delivery
Primary
Prevention
Acute
Care
IntegratedDischargeTeam
IntegratedPrimaryCareTeam
Telehealth/ Care/ Medicine
Shared care plans
Psychological Liaison
Discharge Nurses
Case Management
Discharge Planning Teams
Pharmacy
Specialist Services – for example
Diabetologist & Respiratory
Consultant
Impact/RR
Falls
OT/ Physio
Specialist
Nurses
Geriatricians
Mental Health
Enablement
Twilight
Ambulance
10K Population
GP
District
Nurses
30K Population
Dementia
Adult Mental
Health
Health Visiting
Case Management
Community Pharmacy
Single Point of
Access
LRU + LRMS

14. Measuring Success
• Patient outcome and experience measures
(national voices “I” statements)
• Whole system impact – reduction in
emergency admissions and social care
placements
• Financial sustainability
• Individual project performance indicators
• New integrated models of commissioning
and procurement.

15. Any Questions?