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What Matters to Me - Integrated Care Council

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What Matters to Me - Integrated Care Council
Improving Outcomes through
Integrated Care
Dr Anne Hendry
National Clinical Lead for Integrated Care
Joint Improvement Team
What Matters to Me
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Coordination and continuity of care
Trusted relationships
Accessible information and advice
Good communication with, and between, staff
People living in more deprived areas in Scotland develop multimorbidity
10 years before those living in the most affluent areas
Mental health problems are strongly associated with the number of physical conditions,
particularly in deprived areas in Scotland
Public Bodies (Joint Working)
(Scotland) Act
• Bringing together the accountability of statutory partners
in an equitable way, to deliver better outcomes for
patients, service user and carers - all adults and all care
groups.
Royal
Assent
APRIL
2014
Consultation on
Regulations and
development of
Guidance
APRIL 2014 –
AUGUST 2014
Regulations and
guidance
complete
NOVEMBER
2014 – FEB
2015
Integration
goes live
locally
APRIL 2015
All integrated
arrangements
must be in place
APRIL 2016
2014 National Action Plan for
Multiple Conditions
•Adults with multiple conditions are supported to live
well and experience seamless care from the right
person when they need it and where they want it.
•Scotland is a world leader in research, innovation and
improvement for Multimorbidity and Integrated Care.
4 Primary Drivers
10 Local Actions on three levels:
•
Individual - care planning and consultations that help people to have
control over their conditions, care and support and to achieve their personal
outcomes
•
Local team - integrated care and support that builds on community assets
and promotes independence, wellbeing and resilience
•
Whole system - pathways that are designed around people with multiple
conditions and to reduce health inequalities
5 National actions for Government and Special Boards to drive excellence
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Adaptive leadership
Research, innovation and improvement infrastructure
Technology Enabled Integrated Care
Intermediate Care
> Rapid Response / Early
Supported Discharge
> Reablement
> Hospital at Home
> Step Up / Step Down
community beds
http://www.knowledge.scot.nhs.uk/chin
Residential Care Task Force
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Personalisation
Capacity Planning
Commissioning
Managing Risk
Fee Structure and Funding
Governance and Quality
> Pathfinder project lead by SCVO with East Dunbartonshire
Voluntary Action, Community Health Partnership, Council and local
third sector organisations.
> Working intensively with a number of third sector organisations to
help evidence their impact on community well-being.
> Provides training (delivered by Evaluation Support Scotland) to help
them identify their outcomes and produce the kind of evidence that
will demonstrate their impact.
> www.scvo.org.uk/building-healthier-and-happier-communities
Local Partnerships with Third Sector
All Improvement is Local
> Locality as the Engine Room of Integration
> Where we will best engage and empower those
that deliver and receive health and social care
> Where service changes can have a real and
quick impact on outcomes
Building Trusting Relationships
Supports & Services for Older People in North Lanarkshire
Intermediate Care
Health Promotion
Voluntary Organisations and Supports
Sheltered Housing
Carers Support
Activity Programmes
Care Management
Palliative Care
Community Health
Services
Continence/Falls
Services
Intensive Home
Support
Integrated Health &
Social Care Services
Assistive Technology
Home Support
Very Sheltered
A
Housing
He cute
alt
M
h S ent
erv al
ice
s
Locality Link Officers
Community
Assessment &
Rehabilitation
Respite
Community
Pharmacy
y
nit
u
s
mmpital
o
C os
H
Acute Hospital
Services
Care Homes
Community Alarms
> working seamlessly with colleagues
in NHSScotland and partners who
provide care
> making more and better use of
technology and facilities to increase
access to services
> strengthening workforce planning to
ensure the right people, in the right
numbers, are in the right place, at the
right time
> putting new and extended roles into
practice
Integrated Care Support Worker
9 Health & Wellbeing Outcomes (proposed)
People are able to look after
and improve their own health
and wellbeing and live in good
health for longer.
People, including those with
disabilities, long term
conditions, or who are frail, are
able to live, as far as reasonably
practicable, independently and
at home or in a homely setting
in their community.
People who use health and
social care services have
positive experiences of those
services, and have their dignity
respected.
Health and social care services
are centred on helping to
maintain or improve the
quality of life of service users.
People who provide unpaid
care are supported to reduce
the impact that their caring role
has on their health and
wellbeing.
People who use health and
social care services are safe
from harm.
People who work in health and
social care services are
supported to continuously
improve the information,
support, care and treatment
they provide and feel engaged
with the work they do.
Health and social care services
contribute to reducing health
inequalities
Resources are used effectively
in the provision of health and
social care services, without
waste.
Integrating Care for and with Jessie
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