The document summarizes Salford's Integrated Care Programme, which aims to promote independence for older people through coordinated health and social care. Key elements include Multi-Disciplinary Groups providing targeted support; a Centre of Contact acting as a central hub; and local community assets enabling independent living. The goals are better outcomes, improved experiences, and reduced costs through a person-centered approach.

1. Salford’s Integrated Care Programme
“Developing an integrated care
community- Delivering in
Partnership”
Melanie Walters
Making Integration Work
10th December 2014

2. Statutory
partners
Salix Health

3. • Integrated care programme initiated in late 2011,
formalised in May 2012
• Population of circa 230k, of which 35k aged 65+
• Area of significant deprivation and health inequalities
• Largely co-terminus geography: CCG, City Council,
Salford Royal and Greater Manchester West
• History of whole-system redesign and successful
partnership working
3
Background

4. Salford’s Integrated Care Programme
Multi Disciplinary Groups
provide targeted support to
older people who are most at
risk and have a population
focus on screening, primary
prevention and signposting to
community support
3
Local community assets
enable older people to remain
independent, with greater
confidence to manage their
own care
1
Centre of Contact
acts as an central health and
social care hub, supporting
Multi Disciplinary Groups,
helping people to navigate
services and support
mechanisms, and coordinating
telecare monitoring
2
1
Promoting independence
for older people
 Better health and social
care outcomes
 Improved experience for
services users and carers
 Reduced health and
social care costs
2 3

5. WORK IN PROGRESS - DRAFT 14/11/13 5

6. Governance and programme structure

7. 2020 targets – what and why?
Emergency admissions and readmissions
• 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn)
• Reduce readmissions from baseline
• Cash-ability will be effected by a variety of factors
Permanent admissions to residential and nursing care
• 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn)
• Savings directly cashable but need to be offset by cost of alternative care (especially
increased domiciliary care)
Quality of Life, Managing own Condition, Satisfaction
• Maintain or improve position in upper quartile for global measures
• Use of a variety of individual reported outcome measures
Flu vaccine uptake for Older People
• Increase flu uptake rate to 85% (from baseline of 77.2%)
Proportion of Older People that are able to die at home
• Increase to 50% (from baseline of 41%)
Additional local measure selected for BCF
Diagnosis of Dementia against estimated prevalence rates - BCF 7

8. ‘design principles’
What Issues
Population size Core integrated team to cover c.30,000 to 50,000
(all age) population, with some specialist services at
higher level – cluster of teams
Critical mass to support sufficient range
of services and staff
Reflect future demand
Team –
configuration and
location
Include health and social care staff
Often, but not necessarily based on GP practices
and supported by co-location
Can have shared management
and pooled budgets
Role and scope of ‘care coordinators’
Geography Best based on natural communities and patient
flows
Recognise may not ‘fit’ with
organisational boundaries
Information and
Technology
Integrated records, decision support, patient
monitoring and risk stratification (categorising
people into groups according to need / risk)
Both to coordinate care and provide it
Spectrum of needs Avoid excessive focus on highest acuity
(hospitalisation) – balance with earlier intervention
and prevention
E.g. represented by pyramid of need,
Salford ‘just enough care’ model
Spectrum of
services
Ensure include full range of health and social care,
as well as Third sector and wider support
Initially share knowledge of what is
already available
Engage and
empower people
For older people to have greater control
And for staff to further integrate services
E.g. deciding what services and when
E.g. integrate supporting systems
Keep it Simple in
Salford
Make the system understandable for people,
customers and patients.
Priority to reduce hand-offs between
elements in the system
8

9. Salford’s Integrated Care Programme
Multi Disciplinary Groups
provide targeted support to
older people who are most at
risk and have a population
focus on screening, primary
prevention and signposting to
community support
3
Local community assets
enable older people to remain
independent, with greater
confidence to manage their
own care
1
Centre of Contact
acts as an central health and
social care hub, supporting
Multi Disciplinary Groups,
helping people to navigate
services and support
mechanisms, and coordinating
telecare monitoring
2
1
Promoting independence
for older people
 Better health and social
care outcomes
 Improved experience for
services users and carers
 Reduced health and
social care costs
2 3

10. Segmentation, care plans and standards
Sally’s
standards
GP
standards
Carer support
and disease
management
Home care and
intermediate
care standards
10
Wellbeing
Plan
Independence
Plan
Supported
Independence
Plan
Care Plan
Care
Home
standards
Able Sally
71%: c. 24,850
Needs Some Help
17%: c.6,000
Needs More Help
9%: c.3100
Needs A Lot Of Help
3%: c.1050
SHARED CARE PLANS STANDARDS

11. Sally
friendly
schools
11
Sally
volunteers
Sally Friendly City
Sally friendly
supermarkets
& businesses
Befriending
services
Sally’s Standards
Tech and tea
Housing
Transport
Builds on dementia friendly city and maps across to the Social Value Charter

12. Wellbeing plans

13. Centre of Contact (single point of access)
Post
Discharge
Support
Navigation
Remote
Telecare
Monitoring
Providing people with information
about their conditions, promoting
healthy behaviours and helping with
the emotional impact of chronic
illness. People could be followed up
over the phone for a specific period to
encourage them to be more active
participants in their care
Self Care
support
Health
coaching
Proactive follow up for people
following their discharge from
hospital. This could include a phone
call within 48 hours of discharge.
People at ‘high risk’ of readmission
(stage 2 in MDG) would be followed
up for 30 days or more.
Guiding people to the
appropriate part of the health
and social care system to get the
support they need. This function
could link to a directory of
services to support people in
accessing local community assets.
Helping people to gain the
knowledge, skills, tools and
confidence to become active
participants in their care so that
they can reach their self-identified
goals.
This could integrate existing care
monitoring systems (e.g.
community alarms) and new
telehealth solutions, acting as
central monitoring hub.

14. MDG GP Referrals Post Discharge Emergency Admission New Diagnosis
Sally and her
family, carers
Level 1 - Care Navigator, Directory of Services, PLANS, W2W Portal
Level 2 – Care Navigator Sign Posting and Structured Assessment, Rehabilitation,
Reablement and More Specialist Assessment
Health Coaching
Including
Diabetes Care
Call
Redesigned
ASS-CT and
Intermediate
Care SEP
INBOUND + OUTBOUND CALLS
HEALTH COACHING
NAVIGATION
DISEASE MANAGEMENT
TELEHEALTH MONITORING
Ambulance GP Intermediate
Care services
Telehealth +
Telecare +
Equipment
Integrated Teams Cardiac Rehab Pulmonary Rehab
Specialist Support accessed via the Centre of Contact such as: district nursing,
podiatry, occupational therapy, heart failure, COPD, diabetes and other services
14

15. Continuum of Proactive Care Services
Local Commissioned
Service for LTCs*
All adults
Planned for several
years
CCG funded
Rate per
registered patient
NEEDS SOME HELP/
NEEDS MORE HELP
SALLY
Enhanced Service:
Avoiding Admissions
All vulnerable
adults**
Planned for 1 year:
subject to national
review
NHSE funded
Rate per
registered patient
NEEDS SOME HELP/
NEEDS MORE HELP
SALLY
Multidisciplinary
Groups (ICP)
Frail elderly:
approx > 65 yrs
Planned for 4
years
ICP/Better Care
Fund funded
Rate per hour for
MDG meetings
NEEDS MORE HELP/
NEEDS A LOT OF
Accountable GP >75
year olds
>75 year olds
Permanent unless
contract changes
NHSE funded
Part of core
contract
NEEDS MORE HELP/
NEEDS A LOT OF
HELP SALLY
End of Life Care/GSF
Last year of life
Permanent unless
QoF changes
NHSE funded
QoF Payment
NEEDS A LOT OF
HELP SALLY
Shared care record

16. Principles
• System shifts from reacting
to anticipating
• Personalised, shared care
planning – Sally at the centre
• Tell your story once, have
one assessment, one key
worker, supported by one
integrated system
• Outcomes driven support
Enablers
• Alliance Agreement
• Pooled fund covering most
health and social care
• Four-year investment and
savings plan (BCF+)
• Workforce development
• Organisational development
• Routine progress review
16

17. Alliance Agreement
Lead Commissioner
P
P
P
P P P
BENEFITS
 Full range of services within a single
management arrangement – more effective,
efficient and coordinated care
 Collaborative environment without the need for
new organisational forms
 Aligns interests of commissioners and providers,
removing organisational and professional ‘silos’
that contribute to fragmented and sub-optimal
care
 Collective ownership of opportunities and
responsibilities; any ‘gain’ or ‘pain’ is linked to
performance overall
 Supports a focus on outcomes and incentivises
better management of population demand
 Progressing framework for an integrated care
organisation
 Commitment to move to all adult population
• CCG, City Council, SRFT, GMW
• Health, social care & wellbeing for 65+
population
• Some services subcontracted
• Includes commissioned 3rd sector
services
17

18. Challenges & Critical Success Factors
Challenges
• Implementing change
whilst keeping up with
today’s work
• Pressures on primary
care
• Current model of
primary care provision
• Data & information
sharing
• Intermediate care- best
fit
Success Factors
• Senior leadership
• Governance
• Common vision
• Trust
• Communication
• Function v form
• Carrots and sticks
• Investment in programme
management/
operational posts to
support the work

19. Integrated Care -
everyone playing their part
Much more than a partnership!