Session from managers and front line staff about how to develop such a service, what its impact has been on improving outcomes for older people, the importance of GP practice participation, what the organisational/delivery challenges are and how differences in professional governance and statutory functions have been addressed. Contributed by: East Renfrewshire CHCP

1. Integrated/Co-located
Anticipatory Support Services for
Older People
Tim Eltringham
Head of Health and Community Care
East Renfrewshire CHCP

2. Outline
• Background
• Where we started
• Problems
• Redesign Process
• Reshaping Care
• Alignment to GPs
• Implementation
• Outstanding Issues

3. East Renfrewshire
• South of
Glasgow
• 90,000 people
• Relatively
affluent
• Highest
proportion of
people over 65 in
NHSGGC

4. CHCP
• Single Committee
• Single Director
accountable to 2 CEs
• Managing all SW and
NHS Community
services
• Integrated Management
Team
• CSWO at Head of
Service level

5. Teams involved in Redesign
Older People and Physical Disability
• 3 NHS Rehab Teams
• 5 Social work teams
• 2 Occupational Therapy Teams
• District Nursing Service
• OAMH for part of the area

6. Where we started
Hospital
SW Duty
SW
OT
Rehab
OT Duty
GP
Public

7. Problems we saw
• Numerous ways into service
• Spreadsheets/books/multiple recording
• Handovers
• Duplication of information
• Numerous contacts with service users
• Checking
• Progress chasing
• IT system issues

8. Emerging thinking
• Existing arrangements not working
• Long Term Conditions and Social Work
• GPs as the universal service
• Engagement with practices
• Pilot work with GP team meetings

9. The Redesign Process
• Time, Time, Time
• Clarity of Purpose:
Outcomes
• Process Culture
• Staff engagement
• Staff side
engagement

10. Issues we worked on
• Development of the Management Structure
• Alignment of Rehab Staff
• Processes to manage referrals/demand (inc
Duty)
• Professional leadership
• Administration Support
• Accommodation
• Linkage with hospitals
• Process for transition including scenario
planning
• Staff Briefings
• Team building pre and post implementation

11. Governance
• Different professions have different
requirements
• Social Work Delegated Authority
• NHS Autonomous Practice

12. New Structure
RES Manager
Levern Valley
Service Manager
Eastwood 1
Service Manager
Eastwood 2
Service Manager
Team Manager
Team Manager
Team Manager
Team Manager
Team Manager
Team Manager
Team Manager
Team ManagerNote: OAMH Function
District NursingDistrict Nursing District Nursing
Jewish Care

13. Systems
• Go Live September 2013
• Single Point of Access
• SCI referrals from GPs
• MDT Action Team triage referrals
• Attendance at GP Meetings
• Community-based Geriatrician meetings

14. Performance Improvement
• Not target driven
• Measures are to
improve performance
• Measures Board in
development
- Admission rates
- Delayed Discharges
- Throughput
- Outcomes

15. Anticipatory Care Planning
• Investment in Advanced Nurse
Practitioners
• “Anticipatory Care is everyone’s
business”
• Pathways and paperwork in
development
• Integrated learning approach being
adopted

16. Outstanding Issues
• Data sharing
• Consent
• Improving integration with OAMHT
• Getting time to work pro-actively with
GPs
• Alignment of ACP work by teams and
GPs

17. Is it working?