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Pp slide set 14 older people's health and care pathway
- 1. 3/17/2015 July 2013 Older People’s Health and Care Pathway 1Older people's health and care pathway
- 2. 3/17/2015 Why focus on older people? 46 35 38 58 Spend on >65 as % of Totals HCHS Primary Care Prescriptions Social Care % Total of Population 0.0 5.0 10.0 15.0 20.0 25.0 1948 2008 2048 >65 >75 >85 2Older people's health and care pathway
- 3. 3/17/2015 Mind the Gap! Older people's health and care pathway 3 Strategy Systems Culture Identity National service Part of national identity Primary accountability via NHs Hierachy to SOS / Parliament Adult Social Care Nationally Directed via NCB Marketisation Consistent Clinical and professional standards Flat funding Locally directed Personalisation Significant local variation Care standards 25% funding reductions Local care services Part of local councils Primary accountability via Local Councillors Few national providers + many small local providers Local council T&Cs Local democratic accounatbility Major Regulated Providers e.g. FTs National prices National T&Cs Strong performance mgt Political culture Weak provider influence Professionally dominated Strong provider influence
- 4. 3/17/2015 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
- 5. 3/17/2015 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
- 6. 3/17/2015 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
- 7. 3/17/2015 Person-centred health & care pathway 7Older people's health and care pathway
- 8. 3/17/2015 Person-centred health & care pathway Significant Events Equilibrium - 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 8Older people's health and care pathway
- 9. 3/17/2015 Stage 5 Palliate (end of life care) Stage 3 Treatment / Care Planning and Delivery Stage 4 Return to equilibrium via rehabilitation & reablement Stage 2 Diagnosis/ Needs Identification Stage 1 Presentation & Assessment Stage 0: Equilibrium in the normal place of residence Person-centred health & care pathway showing flows 9Older people's health and care pathway
- 10. 3/17/2015 Example spend across stages & agency 10Older people's health and care pathway
- 11. 3/17/2015 Best Practice Framework Pathway Stage Category 0 Prevention 0 Information, 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
- 12. 3/17/2015 Applying Best Practice Investment/Benefit matrix (example H&SC system) Benefit Invest 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
- 13. 3/17/2015 Example - Intermediate Care in Hackney Older people's health and care pathway 13
- 14. 3/17/2015 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