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Introducing our new model of careSteven Edgar
Vice Chair, Symphony Programme Board and Lead for New Models of Care
135,000 population, older age profile30,000 with long term conditions19 GP practices2 community hospitalsCommunity mental health team1 district general hospitalPoor public transportPredominantly small market towns and villages
About South Somerset
The Idea: Our enhanced primary care modelThe patient and key worker are supported by the wider care team and a number of care programmes and services
Patient with Chronic Condition
Key Worker / Health Coach
GP
Care Programmes & Specialists
Other programmes…
Extended Care TeamTherapies e.g. Physio
Mental Health
Social Care
CHF
Respiratory
Diabetes
Dementia
Network of Services
Care HomeAcute Care
Advanced Diagnostics
InterfaceCore Care Team Key Elements
Team Working and Huddle
Triage
Stratification and Proactive Outreach
Care Planning and Coordination
Defined Workflows and Programme Integration
Aligned Resources and Incentives
Shared Clinical Data and Population Health Analytics
Practice Nurse
Other services…
Symphony Integrated Healthcare
• Impact and success - what we have learnt• Building partnerships and sharing our success
with others• Our key message for the health and care
system.
Wellbeing Erewash• Carol Foster, Programme Lead• Stephen Reid, Person-centred approaches co-
ordinator• Julie Wagstaff, Citizen of Erewash
We are supporting the implementation of person centred approaches for all organisations working with people within
the Erewash area, across all services, people and communities to change conversations.
Group level change
J Michael McGinnis, Pamela Williams-Russo and James R. Knickman. The Case For More Active Policy Attention To Health Promotion Health Attention Affairs, 21, no. 2 (2002): 78-93 – adapted from http://www.kingsfund.org/time-to-think-differently/trends/broader-determinants-health
Health and wellbeing
Choice, no responsibility
Health and safety dictates lifestyle
Balance
Circles of support
PayKnow
FriendsLove
My wellbeing plan1. How do I keep well day to day and what does ‘good’ look like? (daily
maintenance plan)2. People who can help me3. Challenges/ Triggers (things that make me less well) and my action plan4. My early warning signs/ wake up calls and my action plan5. When things get worse - crisis plan6. Advanced decisions.
Wellbeing planning
• End of Life Care in South Derbyshire• A&E at the Derby Royal Hospital• Sharing information with Shropshire STP• North Derbyshire
How we are applying that learning further afield in other
communities”
Accountable Clinical Network for Cancer
Ben Gilchrest
Health as a social movement and the Greater Manchester Cancer Vanguard
• Connecting and catalysing a social movement for cancer prevention – what we are doing…
• Learning – ‘the truth is out there!’• Recommendation – the golden thread through the six
principles for new care models
Better Care Together (Morecambe Bay)
• Sophy Stewart, Head of Engagement and Communications
• Jacqui Thompson, Senior manager for planning and partnerships
What are “people”?
Lets talk about men…
“Men over 60 are….”
Not the same!
What are “communities”?
• Communities of interest: may share common interests e.g. sport and social club
• Communities of action: want to bring change e.g. suffragettes• Communities of place: bound by geography e.g. Morecambe• Communities of practice e.g. people who share a concern or a passion
for something they do• Communities of circumstance e.g. brought together by events
This what we have learnt in our “communities”
Millom
This is how we are applying that learning further afield in other
“communities”
Carnforth
This is how we are applying that learning further afield in other
“communities”
Barrow Morecambe Kendal
Our key message for the health and care system is…
Thank you for listening
System Level Change in Stockport
Nick DixonCommissioning Manager
Stockport Metropolitan Borough Council
Application of learningA ‘Stockport Call to Action’
Four areas to consider
Workforce training and tools
• Who are your workforce?• Relationships matter so
much• Transformational change
can only go at the speed of trust
• We hired workers but human beings came instead
• Resistance- understand why
• Single organisational development strategy with agreed vision
• Leaders set the culture• System translators.
Workforce training and tools
• Rich resource in the community and the voluntary sector
• Work in neighbourhoods people identify
• Go where the fires are burning
• Use the community hubs which exist- map the assets
• Provide information and advice, signposting, digital hubs, link to the prevention services
• Bridge Place and Health: connect to the new care model team
Workforce training and tools
• Activated patients taking more responsibility• More aware citizens wanting change• Community champions and conversations• Compassion inherent in communities;
loneliness- an unnatural disaster• The VCSE can broker the conversations:
“the Council kills it”• Faith groups, businesses, arts, housing,
leisure, fire• Top down, bottom up AND outside in
change.
Workforce training and tools
• How is the VCSE commissioned?
• Commission for outcomes including social capital
• Alliance contracting• Asset based
commissioning across age and label
• Creative use of the resources available
• Commitment devices• Investment funds
Empowering patients and communities
Chair: Anu Singh Director of Patient and Public Voice
and Insight
The NHS Five Year Forward View People and Communities Board have given us six principles to
engage people and communities.
Six principles
• Empowering people is about enabling people to become active partners in their own care, to have the confidence, knowledge and skills to manage their health.
• Empowering communities is about making connections and enabling community activities that provide a network of support options from support groups to gardening clubs to give people the opportunities to self care.
What does this mean?
Using proven evidenced based approaches:
• Health coaching• Peer support• Self management education• group based activities• Volunteering• Community development
How do we do this?
At whole population level: partnerships with communities to mobilise assets, build social capital, address the wider determinants of health and tackle inequalities through approaches such as community development, asset based approaches, volunteering and social action
For people with long term conditions: an increase in the number of people with the confidence, knowledge and skills (activation) to manage their health in partnership with their care teams. Personalised care and support planning and a range of self-care support, routinely offered to those who need it and access to community resources through social prescribing For those with complex care needs: more people who feel in control over their care by having integrated personal commissioning (IPC) and personal health budgets; and providing personalised support for carers.
What might we see in five years time?
• Changing behaviours and relationships takes time• Need to be able to identify the people who find managing
their health difficult otherwise we may widen inequalities• This approach does improve peoples lives and reduce
demand, however it all needs to be implemented to be successful.
What are the challenges?
North East Hampshire and Farnham has recently launched its recovery college – offering health and wellbeing courses to service users and members of the public. These educational courses aim to help people improve their health and wellbeing, and include courses in a range of psychological, mental and physical health conditions. Early evaluation of the first cohort has indicated a 26% improvement in self-reported wellbeing.
What's already happening?
In All Together Better Sunderland multispecialty community provider vanguard more than 18,000 volunteers have been engaged as community health champions and they have in turn reached over 104,000 others.
What's already happening?
Our support team• Five delivery partners who will directly support vanguards in developing and refining their
local approach.
Communities of practice• We want to enable health and care communities to learn from each other, and have an
opportunity to develop themselves personally and professionally. • We will build relationships within, outside and across the health and care system that will
encourage ambition, learning, motivation and energy to help deliver initiatives that will empower people and communities.
Contact: [email protected]
Support from the Empowering Patients and Communities team
