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NHS 5YFV Vanguards- Laura Marsh presentation
- 1. Working in partnership with The West Cheshire Way: Changing health and social care in West Cheshire
- 5. Financial context If we continue with the current model of care we need to find efficiencies within the system of:
- 6. Three aims of West Cheshire Way: • Put people at the heart of care • Use what we have got effectively • Strive for excellence
- 9. Patients at the centre of care
- 10. Starting Well • ‘Run a mile a day’ • Co-design pathways including self care • Self Management courses for children and parents • Supporting young carers • Integrated mental health • Childrens ambulatory care enhanced with specialist outreach • 24/7 end of life care Being Well •Integrated access to lifestyle management •Self management courses, 1:1 coaching •Co-design pathways including self care •Year of care •Acute to community redesign - Domestic abuse awareness Ageing Well • Prevention of social isolation • Co-design of pathways including self care • Embed integrated teams • Extend integrated teams • Integrated older peoples mental health • Closer working with care homes including training • 24/7 End of Life care
- 11. Transforming Primary care Clustering – the building block Shared back office efficiencies Manageable population size 25- 30,000 Potential for alternative skill mix Maintain higher level of expertise across wider range of specialties 7 day access Maintain both reactive and proactive care Aligns to integrated care teams
- 12. Measuring success 12 Outcome Example Measures Example metrics upto2018 Reduce avoidable mortality Reduce potential years of life lost from causes amenable to healthcare Increase 5 year survival from Cancer by 5% Reduce number of children who are obese when they leave primary school by 4% Increase Patient Empowerment and Self Care Increase the number of people who feel supported to manage their own condition Increase the health related quality of life for people with a long term condition by 20% Increase The Provision of Care Closer to Home Reduce the time spent in hospital for those with a long term condition Reduce unplanned admissions for Asthma, Diabetes and Epilepsy in under 19s by 5% Reduce avoidable admissions and readmissions to hospital Reduce unplanned admissions. Reduce avoidable emergency readmissions Reduce the number of unplanned admissions for over 65 year olds by 15% Integrated Care Increase the number of patients who are case managed Increase people offered rehabilitation services following discharge from an acute or
- 13. Achievements so far…. Shared vision: West Cheshire Way Dischar ge to Assess 9 integrated teams inc. nurses social care, care co- ordinators IPH Mental Health Integrated early support for complex families Share d Care Recor d Centre for workforce development and health improvemen t science System- wide outcome measure s and combine d CQUIN Pooled budget through Better Care Fund (£24millio n) Econo my wide financ ial plan
- 14. ICT Cheshire-Wide Forum People & Organisations Forum West Cheshire Strategic Leadership Group Governance Structure Stabilisation Delivery Committee Transformation Delivery Committee Intermediate Care Operational Delivery Committee Acute Care Operational Delivery Committee Planned Care Operational Delivery Committee Mental Health Programme Assurance Board Learning Disabilities Partnership Board Ageing Well Working Group Being Well Working Group Primary Care Working Group Starting Well Working Group Communications and Engagement Forum
Editor's Notes
- Drivers for change: Growing elderly population, reducing finances, growing urgent demand, need to make better use of technology
- Basis of the model for integrated health and social care in the future. Importance of patient at the centre with social movement around their involvement in care and organisational ambiguity
- This is John’s story – this along with other examples of poor care (such as Peter’s story) are what has motivated us as a health and care economy to deliver the West Cheshire Way. We will continue to listen to patient experiences as a touchstone for measuring success
- New care model based on clusters of 3-4 GP practices with their integrated team wrapped around. The clusters of GP practices then work together across a locality. There are three clinical work streams covering whole pathway of care from prevention through to acute care – looking at how we identify care needs earlier, supporting people to self care and then ensuring that wherever possible they are cared for in the community by enabling specialists to reach out and integrate/wrap around GPs and community clinicians. Supported by enablers of ICT, workforce, leadership and change, community conversation about how they can take greater ownership and involvement in care.
- Patient at the centre with their practice supporting them. Increasingly practices will support each other as a cluster to provide greater access for patients and a wider range of services. For those with more complex needs, they will be supported by the integrated care team which includes, community nurses, therapists, social care working together through one case manager and a care coordinator. The integrated care team and GP cluster will then be supported by specialist experts reaching out from the acute trust to enable more people to be cared for in the community.
- We are developing a Transformation dashboard that will help us track whether the things we are doing are having the expected impact. This illustrates the types of outcomes we want to achieve