RESHAPING CARE FOR OLDER
PEOPLE AND CHANGE PLANS
Outer Hebrides Community
Planning Partnership
David Pigott JIT Associate
Reshaping Care For Older
People - Policy Goal:
To optimise the independence and
wellbeing of older people at home or in a
homely setting
Reshaping Care for Older
People Commitments
> Double the proportion of the total health and
social care budget for older people that is spent
on care at home
> Build the capacity of third sector partners to help
them do more to support the experience, assets
and capabilities of older people
> Introduce a Change Fund of in the region of
£300 million over the period 2011/12 to 2014/15
> Shift resources to unpaid carers – at least 20%
of fund
Reshaping Care for Older
People Commitments
> Improve quality and productivity through reducing waste
and unnecessary variation re emergency bed days
> Reduce rates of emergency bed days used by those aged
75+ by a minimum of 20% by 2021 and at least 10% by
2014/15
> Ensure older people are not admitted directly to long term
institutional care from an acute hospital
> All older people over 75 years will be offered a telecare
package in accordance with their assessed needs
Shifting the balance….towards:
 Greater emphasis on preventative and anticipatory care
 A focus on recovery, rehabilitation and re-ablement
 Risk aware (not risk averse)
 Supporting engagement, self-worth and contributions (an
asset based approach)
 Good information, advice and support to enable control
and personalised care
 Good information, advice and support for unpaid carers
 Better alternatives to reduce bed days following
emergency hospital admissions
 Integrated care and support and strong joint
commissioning
The Change Plans and
Reshaping Care
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£80 million 2012/2013,circa £300 million over 4 years.
A Programme for Change – 10 year Delivery Plan
Updated Change Plans developed in the Spring
Slow spend in year 1
Partnership planning process – Health, Local Government,
third and independent sectors
Development of joint commissioning strategies – to 2020
including funding and demographic projections for future
years
Consolidate 2011/12 actions and build on wide range of
other innovative work underway , including Dementia
From 2012/13 demonstrate at least 20% of spend
dedicated to supporting carers
Bridging finance to lever improvement across the entirety
of older people’s spend in health and social care
Meeting the challenges
Demographic changes & finance
Increased numbers requiring care & support
within a tight financial envelope
Status Quo will not suffice
Shifts to anticipatory and preventative
approaches
Care based on principles of Co Production and
effective partnership
Change
Fund
leverage
Change Fund=1%-2%
Existing=98%-99%
Health and social care expenditure
Scottish population aged 65+
(2007/08 total=£4.5bn)
Other Social Work
Care Homes
£0.2bn
Emergency admissions
£0.6bn
£1.4bn
Home Care
£0.3bn
FHS
£0.4bn
£0.4bn
£0.4bn
£0.8bn
Other Hospital care
Prescribing
Community
NATIONAL RESHAPING CARE PATHWAY (11/12 – mid-year review), (11/12 – plans) & (12/13)
Preventative and
Anticipatory Care
(18%) (19%) (22%)
Proactive Care and
Support at Home
(24%) (26%) (25%)
Effective Care at Times
of Transition
(33%) (24%) (28%)
Build social networks
and opportunities for
participation.
Responsive and
flexible home care.
Reablement &
Rehabilitation.
Urgent triage to identify
frail older people.
Early diagnosis of
dementia.
Integrated Case/Care
Management.
Specialist clinical
advice for community
teams.
Prevention of Falls and
Fractures.
Carer Support and
Respite.
NHS24, SAS and Out
of Hours access ACPs.
Early assessment and
rehab in the
appropriate specialist
unit.
Rapid access to
equipment.
Range of Intermediate
Care alternatives to
emergency admission.
Information & Support
for Self Management.
Prediction of risk of
recurrent admissions.
Anticipatory Care
Planning.
Suitable, and varied,
housing, build support
and housing support.
Timely adaptations,
including housing
adaptations and
Telehealthcare.
Hospital and Care
Home(s)
(19%) (23%) (16%)
Prevention and
treatment of delirium.
Responsive and
flexible palliative care.
Effective and timely
discharge home or
transfer to intermediate
care.
Medicines
Management.
Medicine reconciliation
and reviews.
Access to range of
housing options.
Specialist clinical
support for care
homes.
Enablers (6%) (7%) (8%)
Outcomes-focussed assessment
Co-production
Technology/eHealth/Data Sharing
Workforce Development/Skill Mix/Integrated Working
OD and Improvement Support
Information and Evaluation
Commissioning and Integrated Resource Framework
measuring shifts in balance of
Care from institutions to home
 Partnerships need to know impact of actions
 Assurance also required for Ministerial Strategic
Group
 Nationally available Outcome measures and
indicators available for use
 Local Improvement measures where required
 Partnership Resource Use – Integrated
Resource Framework
 Community Care Outcomes Framework
 Sustainability – Life after Change Fund
 Monitoring along the reshaping care pathway
Prevention and Early Identification
 Learning from other programmes – e.g Dementia
and associated demonstrator projects and
research; Long Term Conditions; Carer Strategy
 Housing Strategy
 Community Capacity , Co-production &
information investment
 Social Networks
 Prevention of falls
 Prediction of risk – SPARRA – Primary Care
 Anticipatory Care Planning
Core Improvement Measures
National Outcome measures and indicators
 Emergency admission bed day rates over 75s;
 delayed discharges data ;
 prevalence rates for diagnosis of dementia;
 % 65+ who live in housing rather than care
home/hospital
 % time in last 6 months of life spent at home or
in community setting;
 user and carer experiences
Local Improvement Measures
Anticipatory and preventative
 Proportion of over 75s at home with anticipatory care plan
shared with out of hours staff;
 Waiting time between request for adaptation, assessment
of need and delivery ;
 Proportion of over 75s with telecare; reduction in support
required after reablement ;
 respite care per 1000 pop ;
Acute demand and effective flow in Acute Care
 rates of 65+ to A&E after fall;
 proportion frail emergency admissions access to geriatric
assessment within 24 hrs ;
Long Term Residential Care
 level of admission of new entrants from home; hospital;
after intermediate care ; graduate from emergency respite
Partnership Resource Use
 Integrated Resource Framework data will be
particularly useful
 Per Capita weighted cost of accumulated bed
days lost to delayed discharge
 Cost of emergency bed days for over 75s per
1000 population
 A measure of balance of care split between
spend on institutional and community based care
Supporting Learning and Improvement
 Improvement Network established
 Regular network newsletters / Website
 Learning events and Web Ex sessions
 Gathering intelligence and disseminating examples of
initiatives
 Specific development activities / events e.g. Joint
Commissioning Strategies
 Involvement in development work on performance
framework
 JIT link people to each partnership
 Community capacity and Co-production support
 Carers Issues support
Other Areas of Direct Impact on
Change Plans
 potential further integration of health and
Social Care subject to legislation
 closer working between statutory
partners to deliver better outcomes for all
adults, bringing together health and social
care resources, financial and operational
Self Directed support Bill – partnerships
to ensure SDS central to service options
developed under change fund
www.jitscotland.org.uk