14
3/20/22 July 2013 Older People’s Health and Care Pathway 1 Older people's health and care pathway

Pp slide set 14 older people's health and care pathway

Embed Size (px)

Citation preview

4/7/2014

July 2013

Older People’s Health and Care Pathway

1Older people's health and care pathway

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

7Older 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

Example spend across stages & agency

10Older 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

Example - Intermediate Care in Hackney

Older people's health and care pathway 13

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