Integration – empowering
people to stay at home
NHS Great Yarmouth and
Waveney Integrated Care System
“Nothing between us that we cannot resolve.”
Introduction
Great
Yarmouth
and
Waveney
The Integrated Care System
Initial Key
Focus Areas
Seven Day
Services
ADMISSIONS AVOIDANCE
• Reduce unplanned care admissions
• Keeping people out of hospital
One
team
PERSON
One
commitment
DISCHARGE
•
•
•
•
Early assessment
Timely
Care in right place
Avoid readmission
One
shared
vision
One ICS
UNPLANNED
CARE
• Early diagnosis
• Right care, right place
• Reduced length of stay
Why a 24/7 Out of Hospital
Model?
Patients told us it’s what they want – to stay at home
It offers • Better patient experience; retain independence
Administrators
• Recover faster & more fully
• Improved dignity
• Reduced exposure to communal
Day
Coordinators
acquired infections
(Health) &
Duty Workers
(Social)
It helps the GY&W system •
•
•
Reduced number of emergency
admissions
Reduced length of stay /
timely discharge
Reduced reliance on long term
care placements
GP
Independent
Nurse
Prescribers
Patient,
Family,
Carer
Social Work
Practitioners &
Assessors
Community
Phlebotomists
Beds
Generic
Workers
With
CARE
Senior
Community
Nurses &
Therapists
Rehabilitation
& Reablement
Practitioners
The Integrated Community Care Hub
Kirkley Mill, Lowestoft
• Out of Hospital Team
• GPs, in and out of hours
• Therapists and Podiatrists
• Community Nurses and Phlebotomists
• Social Work Practitioners
• Community Mental Health Practitioners
• Paramedics
• Pharmacists
• Community Support Workers
Case Study
Before
Taken to her bed
Malnourished
Dehydrated
Not taking medication
Dog and human faeces
Joint Assessment within 2 hours of
referral
After
Medically stable
Managing medication
Self caring – x 1 daily carer
Attendance allowance
Safe and clean home
Measures
Measuring
Success
Quantitative
•
•
•
•
KPIs
Activity
 Bed usage
 Other
Clinical Service Reviews
System Finances
Qualitative
•
•
•
•
Patient Feedback
 “Making my life much
easier than it would have
been without their help.”
Staff Feedback
 “Able to provide better and
quicker care.”
Culture Change
Job Satisfaction
Our Learning
•
•
•
•
•
•
Whole system approach
Leaders commitment
Clinical/professional steering/design
Communication
Detailed planning
‘Plans breakdown in the face of the enemy’
so take feedback and evolve
• Significant workforce/HR issues
• Be bold
References
Photographic images used in this presentation were sourced from:
http://delightmakers.com
http://www.chaplinfarrant.com
http://degreesofmoderation.blogspot.co.uk
http://www.documentcapture.co.uk
http://www.hsj.co.uk
NO COPYRIGHT INFRINGEMENT INTENDED
Andy Evans
Chief Executive Officer
NHS Great Yarmouth and Waveney CCG
andy.evans2@nhs.net
Adele Madin
Director of Adult Services
East Coast Community Healthcare
adele.madin@nhs.net
Shaun Overy
Area Manager for Adult Care (Waveney)
Suffolk County Council
shaun.overy@suffolk.gov.uk