Social Isolation in Older People
26th June 2014
Dr Bernie Gregory
Clinical Lead for Well Connected
1
Well Connected
• Coordinated Person Centred Care
• Formal collaboration of all local NHS
health and social care providers,
commissioners, Healthwatch and
voluntary and community groups.
• Need and desire to transform the way
health and care is provided in
Worcestershire.
2
Well Connected
• Launched in spring of 2013.
• National Integration Pioneer in
November 2013
• Support for being braver, moving faster
and at greater scale.
3
Our Vision
“You plan your care with people who work
together with you to understand you and
your needs, allow you control and coordinate and deliver services that support
you to achieve the outcomes important to
you”.
National Voices
4
Our vision
1.Better Experience
for service user,
families and carers
2. Service Users,
families and
carers at the
centre
4. Care centred
around your GP
practice and the
community
3. Looking after
ourselves and
each other
5. Focus on
communities
with the poorest
health
5
AIMS OF THE WELL CONNECTED PROGRAMME
Better
Experience for
service user,
families and
carers
Service Users,
families and
carers at the
centre
Care centred
around your GP
practice and the
community
Looking after
ourselves and
each other
Focus on
communities
with the
poorest health
6
AIMS OF THE WELL CONNECTED PROGRAMME
Better Experience
for service user,
families and carers
Service Users,
families and
carers at the
centre
Care centred
around your GP
practice and the
community
Looking after
ourselves and
each other
Focus on
communities
with the poorest
health
7
AIMS OF THE WELL CONNECTED PROGRAMME-
Better Experience
for service user,
families and carers
Service Users,
families and
carers at the
centre
Care centred
around your GP
practice and the
community
Looking after
ourselves and
each other
Focus on
communities
with the poorest
health
8
AIMS OF THE WELL CONNECTED PROGRAMME
Better Experience
for service user,
families and carers
Service Users,
families and
carers at the
centre
Care centred
around your
GP practice
and the
community
Looking after
ourselves and
each other
Focus on
communities
with the poorest
health
9
AIMS OF THE WELL CONNECTED PROGRAMME
Better Experience
for service user,
families and carers
Service Users,
families and
carers at the
centre
Care centred
around your GP
practice and the
community
Looking after
ourselves and
each other
Focus on
communities
with the
poorest health
10
Well Connected Programme
Healthy living
and wellbeing
Maintaining
independence
Proactive care
Discharge to
assess
Crisis
intervention,
admissions
avoidance
Bedded care
11
Well Connected Programme
Healthy living
and wellbeing
Maintaining
independence
Proactive care
Discharge to
assess
Crisis
intervention,
admissions
avoidance
Bedded care
12
Well Connected Programme
Healthy living
and wellbeing
Maintaining
independence
Proactive
care
Discharge to
assess
Crisis
intervention,
admissions
avoidance
Bedded care
13
Well Connected Programme
Healthy living
and wellbeing
Maintaining
independence
Proactive care
Discharge
to assess
Crisis
intervention,
admissions
avoidance
Bedded
care
14
Well Connected Programme
Healthy living
and
wellbeing
Maintaining
independence
Proactive
care
Discharge to
assess
Crisis
intervention,
admissions
avoidance
Bedded care
15
5 year
Health and Care Strategy
for Worcestershire
Developed with input from:
10th
Draft v5.1
June 2014
Our Five Year Strategic Plan on a Page
Worcestershire Joint Health and Well Being Strategy
Our vision for health and care in Worcestershire
You plan your care with people who work together with you to understand you and your needs, allow you control and co-ordinate and deliver services that support you
to achieve the outcomes important to you.
• A seamless health and social care system delivering high quality, timely and
• Investment in prediction, prevention and early intervention where we can be
effective care;
confident that this will reduce future demand on services;
• As much care and support provided in or as close to people’s homes as possible; • Residents helped with technology supported self care to ensure that specialist
resources are focused more effectively on those in most need;
• Individuals and families will be able to take greater responsibility and greater
control over their own health and care;
• Reduced differences between social groups in terms of health and social care
outcomes;
• Specialist hospital services, primary care and community care provided from
high quality safe environments, with appropriate qualified, supported and
• A financially sustainable model of care that targets the use of resources in those
skilled staff working across 7 days.
areas that will have greatest impact.
Values and principles underpinning our health and care economy
Organisations
Patients and the
population come work together to
deliver change,
first, not
not in
organisational
competition.
interests.
We work with a no
blame culture where
the focus is on finding
solutions not blaming
for problems.
We balance need
for consistency
across the county
with the specific
needs local
populations.
All decisions considered in We respect the views of the We will work to deliver
the light of the health and public, patients, service users
financial balance,
care needs of the
sustainability and
and carers and ensure that
population and the
they have an opportunity to Value for Money in the
evidence base for
delivery of services
shape how services are
what works.
organised and provided.
The outcomes we are seeking to achieve
Additional years All people over 65 or those under 65 living
Emergency
of life secured in with long term conditions (including children
admissions and
conditions
and young people) have their own
length of stay reduced
considered
personalised ‘joined up’ care plan where the
by managing care
amenable to
priorities set by the individual are supported
more proactively
healthcare.
by the care that they receive, resulting in
in other settings.
improved health related quality of life.
Safe and effective care
secured and the proportion
of people having a positive
experience of care in all
settings increased.
Parity of esteem for
The need for long term
residential and nursing people suffering with
mental health
care for all age groups is
reduced by people being conditions alongside
those with physical
healthy and
health conditions.
independently.
Worcestershire Joint Health and Well Being Strategy
Page 17
Draft
Better Care Fund
•
June 2013 announcement of the Better Care
Fund to support the integration of health and
social care.
• “a single pooled budget for health and social
care services to work more closely together in
local areas, based on a plan agreed between the
NHS and local authorities”.
• 3.8 billion nationally and minimum of around
£37m for Worcestershire for 15/16. NOT ‘new’
money
• Plans need to meet specific criteria
18
Better Care Fund
• Focus for the Better Care Fund will be to support
people who are currently, or who are at risk for
becoming, heavily dependent on health and
adult social care services
•
Concept of population risk segmentation and
early intervention - developing an end to end
pathway without financial barriers
19
Transforming Primary Care
• Safe, personalised, proactive, out of hospital care
• Proactive Care Programme
• Named GP for all people aged over 75 with
overall responsibility for and oversight of their
care.
• Funds for commissioners to invest in primary
care
20
21