The document discusses integrated health and social care delivery in West Cheshire, England. It notes that an aging population is increasing demands on services while budgets are decreasing. Partners are working to reduce hospital admissions and long-term care placements for over-65s by 25-30% and 15% respectively. The model involves a single point of access, integrated locality teams aligned with GP surgeries, and a shared care record to better coordinate services for improved outcomes and efficiency. Metrics are being developed to measure the model's impact on admissions, readmissions, satisfaction and more.

1. Delivering Integrated Health and Social
Care in West Cheshire: A work in
progress

2. Our context
• People are living longer, and although this is
something to celebrate it also places additional
pressure on health, social care and housing.
• Over the past five years, an 18% rise the number
of people over the age of 85 has resulted in a
40% increase in the number of unplanned
hospital admissions, and a 30% rise in
unplanned hospital bed days
• Locally, £167m is spent on NHS acute and
community care and social care on the over 65s
• At the same time, Local Government is making
budget reductions of 25+% and the NHS is on
‘flat cash’ at a time when demand for acute care
continues to increase
• Using current demographic forecasts it is
estimated that if we were to maintain existing
service delivery mechanisms, we would require
an additional £19.1 million
• Partners across Cheshire have agreed to work together to meet these challenges
• We will initially focus on people aged 65+ who live in Cheshire West who need care
and support or who are at risk
• Specifically, the intention is to reduce non-elective bed day use by those aged over 65
by 25-30%, accompanied by a 15% reduction of placements into long term care with
an initial focus on people aged 85+
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3. 92.0%
1.1%
0.7%
6.2%
At home without formal support
In hospital
Rehab and Reablement
Receiving care at home
8.8% over 65 year old population cost
the health and social care economy
£167 million
Understanding our population
Where are our over
65s?
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4. How is the £167 million
spent?
45.00%
1.00%
20.87%
32.34%
0.57%
Keeping healthy in own place of residence
Presentation and assessment of condition
Diagnosis, treatment and care plan delivery
Return to normal place of residence
End of life care
Understanding our population
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5. What our communities are telling us
When I needed support to live at
home, services worked together to
provide it
When I went to a new service, they
knew who I was, what my
circumstances were, and about my
own views and preferences
When I was discharged from a service,
there was a plan in place for what
happened next
When I used a new service, my care
plan was known in advance and
respected
The information I was given was
comprehensive: it was not just
medical, but also helped me
understand the impact of my health
status on other parts of my life
I could see my health and care records
at any time to check what was going
on
I had one first point of contact. They
understood both me and my
condition. I could go to them with
questions at any time
The professionals involved with me
talked to each other. I could see that
they worked as a team
My residential care provider
maintained close links with the health
and social care professionals and my
GP stayed actively involved in my care
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6. Translating this into our vision
Older people live life to the full in their communities and stay as fit
and well as they can to the end of their lives and, if they need
support, they can exercise real choice and control about the nature
of that support.
Older people who need support will be enabled to live at home by
integrated community services working in a holistic way that is
proportionate to their needs. Older people will only be admitted to
hospital and care homes if the exacerbation of their needs exceeds
the capacity of what can be safely and at least cost delivered in the
community. They should not be cared for in hospitals and care
homes for longer than necessary.
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7. How this translates into a new model of care
7

8. Key elements of
the Care Model
Community
Service-led (in
partnership)
COCH-led (in
partnership)
Jointly-led
Shared enablers
8

9. The new model at a glance: A Wider View

10. How the priority elements of the new
care model are being delivered
10

11. The new care model
A single point of access and common assessment process for health and social care
enabling better access to the right services, a common understanding of need across
agencies, view people in a holistic way looking together at their physical and mental
needs and further sharing of information.
A new approach to encourage stronger communities which treats older adults as assets
and enables communities to help themselves where possible.
A more coherent approach to self-care, maximising the potential of personalisation,
shifting power and responsibility to citizens. Encourages individuals to pursue the 5 ways
to Health and Wellbeing .
A number of integrated locality teams aligned to GP surgeries - bringing together health,
social care, the voluntary and community sector, and other professionals- enabling joint
management of cases and interventions across organisational boundaries

12. Enabling the care model
The development of a shared care record across all health and social care partners in West
Cheshire to support more efficient and effective working and enables the patient to be at
the heart of joint decision making. Flexible and mobile working will be rolled-out to all staff
and ICT will be put in place to support new processes within the care model.
Resources will be shared across all partners in managing the programme of work and
ongoing service delivery. Asset strategies will be joined to enable staff to work together in
an integrated manner, no matter where they were previously based.
Shared systems
and ICT
A new joint workforce development strategy will be in place to support our staff to develop,
learn and co-produce the new care model and new ways of working. Leadership and culture
change are key elements incorporated into this and programme governance will reflect staff,
user and partner involvement.
A new funding and contractual model which provides the right incentives to have a model of
care which shifts activity and resources from inappropriate acute setting towards
community-based care.
Funding and
Contracting Model

13. Single Point of Access and Integrated Teams
13

14. Single Point of Access: The Model

15. Health and
Social Care
Call Handlers
Nurse and
Social Care
Coordinators
West Cheshire Gateway Service – 24/7
response
Front of House Call Management
Call Streaming
Call Triage
Discharge
Management
Admissions
Management
Urgent Response
Referral
Management/routine
response
Outcome
• Step down bed
• Home-based
Intermediate Care
• Community Services
• Reablement
• Residential Care
• Admit to acute care
• Step up bed
• Whole system
communications
• Assessment
• Maintain at home
• Admission to MAU
• Step up bed
• Referral accepted
• Appointment
allocated
Service
response
.
Single Point of Access: How it will work
15

16. Single Point of Access: Progress against the plan
Scale Up Local Interventions
Develop Sustainable Whole-System Model Implementation of Whole-System Model
2013 2014 2015 2016
• Teams and activities
identified
• ‘As-is’ process
mapping
• Demand analysis
• Performance analysis
• Functional analysis
• ‘To-be’ processes
• Staffing alignment
• Extend to 8am-8pm
• Infrastructural
changes
• Staff re-location
• ICT and system
alignment
• Assess progress
• Update performance
framework
Refine Deliver Design Define
2017
Completed
On track /
Ahead

17. Co-ordinated
Points of
Access
Integrated Teams: The Model

18. Integrated Teams: Progress against the plan
Scale Up Local Interventions
Develop Sustainable Whole-System Model Implementation of Whole-System Model
2013 2014 2015 2016
• Teams and activities
identified
• Demand analysis
• Functional analysis
• Staffing alignment
• Team co-location
• ICT and system alignment
• Care Co-ordinators in post
• MDT meetings in place
• Team Go-Live:
• Princeway
• Broxton
• Tarporley
• Lache
• Northgate
• Boughton
• EP North
• EP South
• Neston
• Process alignment –
assessment and referrals
• Assess progress
• Update performance
framework
Refine Deliver Design Define
2017
Completed
On track /
Ahead
Team ‘Live’ and co-located
‘Virtual’ team in place
Scheduled to be ‘Live’ and
co-located

19. Integrated Teams: Team composition and progress
Progress at a glance…
Princeway Broxton Tarporley Lache Northgate Boughton Ellesmere
Port South
Ellesmere
Port North Neston
GP surgeries Helsby
Frodsham
Medical
The Knoll
Malpas
Tattenhall
Farndon
Bunbury
Tarporley x 2
Kelsall
Lache
City Walls
Western Avenue
Handbridge
Northgate
Village
Northgate
Medical
The Elms
Hoole Road
Garden Lane
Boughton
Park
Heath Lane
Upton
Whitby x 3
Old Hall
York Road
Westminster
Great Sutton x
3
Hope Farm
Willaston
Neston
Medical
Neston
Surgery
Practice
population
26,309 14,021 22,736 34,163 36,349 33,433 35,345 31,567 20,176
Population 65+ 5,593 3,093 5,327 7,017 4,778 6,195 5,601 5,703 5,014
Population 85+ 736 410 620 692 872 900 642 640 583
Process / Staff
alignment
Team co-located
Jan 2015 Jan 2015 March 2015
Care co-ordinator
in
place
MDT’s

20.  Agree a shared vision
 Realistic timescales and expectations
 Funding
 Strong leadership
 Robust governance framework
 Engage key enablers esp. ICT and estates
 Joint project planning
 Relationships and ownership
 Co-location
 Integrated management
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Some learning

21. Developing a single outcomes framework to
support all of this
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22. The outcomes framework: Key metrics
Care Model
Metrics
Care Model
metrics with
alignment to
specific
elements
Metrics
specific to
elements of
the Care
Model
Outcome
Type of Benefit
Method of
Measurement
Baseline
Performance Checkpoints
Quality
Productivity
Gain
Cost
Avoidance
Cash
Releasing 3 Months 6 Months 12 Months
Reduction in unplanned admissions
aged 65-84
x
Number of bed days
for patient cohort
by age
824
(monthly
average)
Reduction in the number of older
people, in our care, (aged 65-84)
readmitted within 30 days of
discharge from acute care
x
number of
readmissions within
30 days
249
(monthly
average)
Reduction in A&E attendances for high
frequency users
x
Number of
admissions for this
cohort of patients
TBC
Increase in user satisfaction x Survey TBC
Increase in staff satisfaction x x Survey TBC
Increase in GP satisfaction x x Survey TBC
Increase in the number of single
assessments completed by the
integrated team
x x x
Number of single
assessments and
number of uni-professional
assessments
completed
TBC
The framework in development…
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23. Overseeing and driving delivery
West Cheshire Health & Wellbeing Board
Commissioning Delivery Committee
Joint Accountable Provider Board
Vale Royal CCG
Connecting Care
Programme Board
Connecting Care
Provider Board
CW&C
Strategic
Commissioning
DMT
Pioneer Panel
CWP
CWP Ops Board
Integrated
Community
Services Sub Group
COCH
23
WCCCG
Self-Care
Hospital
Discharge
Integrated
Teams (West)
Integrated
Teams (VR)
Intermediate
Care
(Reablement)
Stronger
Communities
Front of
House / SPA

24. Sandra.birnie@nhs.net
Will.ivatt@cwp.nhs.uk
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