Altogether Better in West Cheshire

Moving toward a whole-system, customer-centric approach to the delivery of health and social care

Amanda Lonsdale – West Cheshire CCGWill Ivatt – Cheshire West and Chester Council

• Setting the scene• A West Cheshire perspective• The Ageing Well Programme• Moving toward a Whole System Approach• What is currently in scope• How it feels on the ground• How we measure success• Our challenges

What does this presentation include?

A Contextual Glance

A Whole-Place community Budget for West Cheshire

The Ageing Well Programme

Moving Toward a ‘Whole-System’ Approach

Pan-Cheshire ‘Pioneers’

Why do we need to do this?A West Cheshire Perspective

The Demographic Challenge

• An additional 19,500 (26% rise) residents over the age of 65• An additional 3,000 (41% rise) residents over the age of 85

1yr 2yrs 3yrs 4yrs 5yrs 6yrs 7yrs 8yrs 9yrs 10yrs

What does this mean?

• Locally we spend £133.6 million annually on health and social care for residents over 65• The biggest areas of spend are long-term care (£28m) and non-elective in patients (£33m)• Point prevalence (2012)showed 25-30% of hospital occupants could be served elsewhere

The Ageing Well Programme

Stronger Communities• Social Isolation, Keep Well

Self-Care• Telecare, Telehealth, Extra Care

Integrated Teams• 9 + 3 integrated community care teams,

Single Front Door

Funding and Contracting Model• New financial model based on Ageing Well

Business Case

What are our current priorities?

• Seeing the person as a whole – asking them what they want

• Moving away from crisis management to prevention and the promotion of wellbeing

• Carers - identification and support • A continued emphasis on joined up

working across health, social care and other partners

• A firm focus on commissioning effective, high quality services, rather than commissioning ‘time slots’

Integrated Communities

Frailty Pathway

West Cheshire Gateway

End of Life

Community Care Teams Dementia Single Referral Community Equipment

MDTs Community Equipment Health & Social Care End of Life

Third Sector Navigators Falls Holistic Patient View Urgent Care

Telecare / Telehealth Intermediate Care

Self Care / Stronger Comm Hospital @ Home

3d Sector Assembly Transitional Beds

Residential Homes

Enablers

Funding & Contracting

Patient Engagement

Information Technology

Workforce Development

Accountable Care Org Shared Record Training & Education

Block/Rolling Contract Risk Stratification HR/OD

Aligned Budget Information Governance

Pooled Budget

Assets

Estates

FInance

5 Year Vision

Pan-Cheshire Pioneer

What’s in scope?

Integrated Teams – A Service Model

Frailty Pathway

Tier 5 End of Life

care

Tier 4More serious exacerbations

Care needs more complex

Tier 3Enduring complex problemCare mostly managed in the

community but requires specialised input

Tier 2Established long term condition or

problem managed in the community setting

Tier 1Development of symptoms

Tier 0Well

Care Approaches Care Settings

Tier 5 – CGA and Palliative Care

Tier 3 and 4 – Comprehensive Geriatric Assessment (GCA), Anticipatory Care Planning and Care ManagementProactive integrated team based multi-disciplinary assessment, rehabilitation, telehealth, support and monitoring

Tier 2 – Assessment, Care Planning, Support and ReviewCare co-ordination, support, rehabilitation, telehealth and carer support

Tier 0 and 1 – Self ManagementInformation, adviceand support to self-manage

Tier 5 – At home. Care Home, Hospice or Community Hospital

Tier 4 – Acute Hospital, Care Home or at home with telehealth advice and support from specialist team

Tier 3 – Community Hospital, Intermediate Care Setting or at home with advice and support

from specialist team

Tier 2 – Community Team and Rehab services

Tier 0 and 1 – GP Practice, Pharmacy, Voluntary and

Community Sector, Home, Web

“My care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes”

(Source: service user perspective from ‘National voices’)

(Source: Kings Fund)

How do we measure success?

• Pick a deadline and stick to it!• Put people at the heart• Integrate where it makes sense• Avoid new silos• Get the ‘governance’ right• Be flexible on geography and client group• Manage expectations• Money talks• Maintain momentum

Lessons learnt (& challenges to address)