Integrated Care:
Integrated Community Services
for Adults
Cath Doman
Head of Community Health Commissioning
Programme Lead Integrated Care
NHS Airedale, Bradford and Leeds
Lyn Sowray
Assistant Director
Adult and Community Services
Bradford Metropolitan District Council
Integrated care programme
• Delivering the vision for integration
• Transformation of health + social care in the
District
• Integration of community services clustered
around GP practice/s
• Services working as a single team for each
locality
• Risk stratification of locality population
In simple terms, it’s…
…whatever the person needs following
(or to prevent) acute care or long-term
dependence
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Reablement
Rehab
Recuperation
Return to optimal health + wellbeing
The vision
Right care
right place
first time
Joined up services to enable people to
regain and keep their optimal health, wellbeing and independence
The health economy
• Need for new models of care delivery
– Funding gap
– Shift from hospital to community requires greater
capacity and productivity in community services
– Growing demand/population requires a preventative
approach
– Increased capacity to prevent needs escalating
– Better case management across partners to reduce
bureaucracy, duplication, risk
Adapted from slide by Nick Morris BDCT
The Partners
Commissioners
• NHS Airedale, Bradford and Leeds
• Emerging Clinical Commissioning Groups
• BMDC
• NYCC (for Craven)
Providers
• Bradford District Care Trust
• Bradford Teaching Hospitals
• Airedale NHS FT
• Bradford Metropolitan Borough Council
• Voluntary and Community Sector
• North Yorkshire County Council
Integrated functions
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Community nursing
Intermediate care services
Community therapy services
Long-term conditions management
Long-term support and care
Rehabilitation and reablement
Associated support services - VCS
Opportunities to include MH + LD services
The programme
Access
Assessment,
diagnosis + care
planning
Community beds
Mental health and dementia
Home-based support
Falls and bone health
Long-term conditions
Enable
Estates
IT
Performance
Assistive technology
VCS
Communications
HR + OD
Finance
Risk stratification
Scale of Step Up Intermediate Care
Principle: Care close to home
Maximise care at home.
Minimise need for hospitalisation.
Dr Tom Downes 2008
Timescale: 2-3 years
• 2011/12 Transfer + achieve consensus
Transfer of community services and development of strategy
Practices putting
in proposals
now
• 2012/13 Change
Early wins: test-sites across District of teams working
together, common criteria, assessment and records,
enablement working alongside therapy and community
nursing
• 2013/14 Polish + make it stick
111, pooled budged, single management, health + social care
services delivered from community-based hubs
Introducing Mrs Jones…
Warde
n
CMHT
Discharge
team
Communit
y Matron
Physi
o
podiatrist
Equipmen
t services
Outpatient
s
Social
worke
r
OT
Social
service
s OT
Home
care
Heart
doc
MATS
BDCT
GP
Distric
t
nurse
Housing
grants
BMDC
InCommunities
BTHFT
ANHSFT
Practic
e nurse
Diabetes
doc
VCS
GP
Discussion and questions