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4/7/2014
Why focus on older people?
46
3538
58
Spend on >65 as % of Totals
HCHS Primary CarePrescriptions Social Care
% Total of Population
1948 2008 20480.0
5.0
10.0
15.0
20.0
25.0
>65 >75 >85
2Older people's health and care pathway
4/7/2014 Older people's health and care pathway 3
Mind the Gap!
Strategy
Systems Culture
Identity
National servicePart of national identityPrimary accountability via NHs Hierachy to SOS / Parliament
Adult Social Care
Nationally Directed via NCBMarketisationConsistent Clinical and professional standardsFlat funding
Locally directedPersonalisationSignificant local variation Care standards 25% funding reductions
Local care servicesPart of local councilsPrimary accountability via Local Councillors
Few national providers + many small local providers Local council T&CsLocal democratic accounatbility
Major Regulated Providers e.g. FTsNational pricesNational T&Cs Strong performance mgt
Political cultureWeak provider influence
Professionally dominatedStrong provider influence
4/7/2014
Significant Events
State A State B
Significant Events often involve a discontinuity or change of state, phase, realm or order
Inputs
Outputs
4Older people's health and care pathway
4/7/2014
Significant Events
A progression, or cluster of progressions, which involves:Significant Creation
– When something significant is created from nothing. A new concept is conceived. The decision point for a new strategy, plan, purpose, objective, concept, design, diagnosis, proof, principle, or ethic. A contractual relationship is formed.
Significant Conversion– A significant conversion or transformation. Inputs die and something new and
purposeful emerges.Significant Inspiration
– When someone is significantly inspired, healed, energised or re-motivated. When something comes alive, is reborn or is restored to what it is meant to be. Something realises its true value and worth. Something new and significant is learnt.
Leading to:Something with a new Identity,and a major contribution to the overall purpose
5Older people's health and care pathway
4/7/2014
Example client system - The Essex Journey
• Multiple projects over last 4 years.• 3 Local Authorities, 5 CCGs & 5 acute hospitals • Combined £1 billion spend on people over 65• Projects including
– Older People’s services strategy– Joint commissioning for OPS.– Urgent care strategy– Community Budgets.– Integrated Commissioning.
6Older people's health and care pathway
4/7/2014
Person-centred health & care pathway
Significant EventsEquilibrium - normal place of residence
Presentation & assessment
Diagnosis/Needs identification
Treatment/ Care Planning and
delivery
Restore to equilibrium
End of Life Care / Palliation
Stage 0 1 2 3 4 5
Home
Supported housing
Community/ Primary Care setting
Intermediate Care setting
Hospital - ambulatory Care
Care Home
Hospital - in-patient care
Emphasis to keep patients/clients at home
Emphasis to keep patients/clients at home
8Older people's health and care pathway
4/7/2014
Stage 5Palliate (end of
life care)
Stage 3Treatment / Care
Planning and Delivery
Stage 4Return to
equilibrium via rehabilitation &
reablement
Stage 2Diagnosis/
Needs Identification
Stage 1Presentation &
Assessment
Stage 0: Equilibrium in
the normal place of residence
Person-centred health & care pathway showing flows
9Older people's health and care pathway
4/7/2014
Best Practice FrameworkPathway Stage Category
0 Prevention
0Information, advice and advocacy
0 Supported self-management, empowerment and peer and community support
0 Assistive technology
0 Housing
0 Case management/virtual ward
1 Initial contact 1 Assessment 4 Re-ablement and rehabilitation
4 Intermediate Care 5 End of Life Care
Cross-cutting Governance/Integration Cross-cutting Efficiency and effectiveness Cross-cutting Policy drivers Cross-cutting Planning Cross-cutting Processes and systems Cross-cutting Carer support
Key emerging themes:
• Place• Keeping people healthy• Crisis anticipation and response• Personal care market
11Older people's health and care pathway
4/7/2014
Applying Best PracticeInvestment/Benefit matrix
(example H&SC system)
Benefit
Inve
st
NHS Both Social care
NHS
Both
Social
care
1
2
3
4
5
6
12
8
9
10 7
13
14
15
16
17
18
19
20 Case mgt, virtual wards & Telehealth with predictive case –finding
Stroke mgt & incontinence
Access to financial information
Reablement
Falls prevention
12Older people's health and care pathway
4/7/2014
Benefits of the pathway framework
• Focus responses around the needs of the person.
• Bridges the structural fault-line by enabling
– Health and social care to consider service responses and resources together
– Alignment of strategies, resources, capacity and governance (including identification of current misalignments)
– Intelligent conversation about investment and benefits realisation
– Simple common language and pathway framework for all staff
– Gathering around a common purpose - to optimise independence and well-being in peoples’ normal place of residence
• Enables vision to deliver all significant events in normal place of residence where possible
14Older people's health and care pathway