Integration : Brian Slater
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Integration is about more than just technical and bureaucratic changes - it requires a new approach to planning services with a shared vision and shift in culture. Additional funding alone will not solve challenges facing the NHS, fundamental reform is needed to deliver care in a new way. Intermediate care services are designed to prevent hospital admission or facilitate faster discharge through a coordinated, holistic approach providing time-limited support to maintain independence at home.
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Integration : Brian Slater
- 1. DELIVERING THROUGH INTEGRATION BRIAN SLATER
- 5. Proportion of delayed discharges by reason for delay; Scotland; Average number across censuses April 2018 - March 2019
- 7. Delayed discharge bed days as a proportion of all occupied bed days by NHS health board of treatment; Scotland; 2018/19
- 8. Standard delays over three days duration
- 9. Delays as a part of occupied bed days
- 10. Mr A’s experience of being delayed in hospital
- 13. A vital part of the jigsaw
- 14. Integration is….. • More than technical and bureaucratic changes • A new approach to planning the delivery of services • A renewed focus on outcomes, less on process • A shared vision and set of values • A shift in culture • Innovative and moving away from risk aversion • Developing new relationships with communities and localities (Christie)
- 15. “The nature and scale of the challenges facing our NHS - in particular the challenge of an ageing population - mean that additional money alone will not equip it properly for the future. To be blunt, if all we do is fund our NHS to deliver more of the same, it will not cope with the pressures it faces. To really protect our NHS, we need to do more than just give it extra money - we need to use that money to deliver fundamental reform and change the way our NHS delivers care." John Swinney, DFM Budget Speech, 12/15
- 18. Rate of hospitalisation – over 65s 0.0% 0.4% 0.8% 1.2% 1.6% 2.0% Aberdeenshire Moray Clackmannans… Argyll&Bute Stirling Highland Dumfries&… OrkneyIslands Perth&Kinross ScottishBorders Angus Falkirk ShetlandIslands EastAyrshire Fife WestLothian NorthAyrshire North… East… East… AberdeenCity EastLothian SouthAyrshire South… Midlothian DundeeCity Renfrewshire EileanSiar West… Cityof… Inverclyde GlasgowCity Proportionof65+population
- 19. Rate of hospitalisation – over 65s 0.0% 0.4% 0.8% 1.2% 1.6% 2.0% Aberdeenshire Moray Clackmannans… Argyll&Bute Stirling Highland Dumfries&… OrkneyIslands Perth&Kinross ScottishBorders Angus Falkirk ShetlandIslands EastAyrshire Fife WestLothian NorthAyrshire North… East… East… AberdeenCity EastLothian SouthAyrshire South… Midlothian DundeeCity Renfrewshire EileanSiar West… Cityof… Inverclyde GlasgowCity Proportionof65+population
- 20. Community Connectors Family/carer support Lunch clubs Befriending Local clubs & activities Third sector Independent sector GPs District Nurses & CPNs AHPs Pharmacies Social workers Homecare Equipment & Adaptations TEC Reablement Homecare Multi-disciplinary teams Rapid Response Step-up/down beds Community wards Short-term intensive homecare Nurses & ANPs TEC monitoring COMMUNITY RESOURCES PRIMARY CARE & COMMUNITY SERVICES COMMUNITY REHAB ENHANCED IC H@H Consultant/GP led Acute hospital level care at home Fast access to labs & diagnostics living well in the community maintaining my health & wellbeing with primary care and community support I am an adult / older person with complex needs…. but need support or equipment to keep me well at home but need fast acting short-term support to keep me well at home, or get me back home quickly but require specialist acute care and treatment to get me well Intermediate Care Services
- 21. Key Components of Intermediate Care Services Clear Scope Focused on prevention, rehab, reablement and recovery Provide a clear understanding of the profile of local needs and how IC can assist Accessible, flexible, responsive Through a single point of contact, 7/24 Provide quick, direct access, avoiding multiple referrals or complex pathways Time Limited Linking and complementing existing services Provided at points of crisis to avoid hospital admission, or aid discharge home Co-ordinated Able to draw on multi- professional and multi- agency skills and resources, as required to meet complex needs Co-ordinated at both system and operational level. Holistic Assessment Aimed at maximizing independence, confidence and personal outcomes. Individuals eligible for IC should be identified and prioritised quickly to ensure access to the appropriate service without delay
- 22. Delayed Discharge Expert Group Report (2011)
- 26. Partnership visits – key themes • Strong leadership • with staff empowered to make decisions – and take risks • Initiatives rolled out ward by ward to instil staff confidence in changes • Early referral to / involvement of social work, with • Multi-disciplinary discharge hubs, ideally including housing and carer support, • Discharge huddles • A Home First focus • Involving the Third Sector e.g. Red Cross schemes Assessment at home / home from hospital services • GP involvement • Clear, single referral pathways for all Intermediate Care services • Back home boxes • Dedicated Mental Health Officer to reduce length and number of AWI delays
- 27. Hearts and Minds