Integration at Torbay Care Trust

1
Integration at Torbay Care Trust

• Sonja Stefanics
• General Manager Health Social Care
• May 2009

2
Overview

• How did we get here? The Integration Story
• Where are we now? Integration 4 years on
• What were the success factors?
• What difference has it made?
• Further developments
• Questions

3
Who are we?

• Torbay Centred around towns of Torquay,
  Paignton and Brixham
• Total population of 140,000 in the bay with 23
  over 65
• Co-terminous with Torbay Council unitary
  authority
• Acute services mainly commissioned from local
  hospital South Devon Healthcare Foundation
  Trust
• 21 GP practices

4
Who we are?

• One of only 5 Care Trusts in the country
  created December 2005
• Responsible for commissioning and providing all
  adult health and social care services for people
  of Torbay
• Total system integration of community health and
  social care
• Integrated teams supporting 5 groups of GP
  practices
• Passionate about integrating and improving
  services for Mrs Smith

5
The Integration Story

• What people told us they wanted from an
  integrated service
• Single point of contact
• Quick and responsive services
• Didnt want to tell their story twice
• Wanted professionals to talk to each other
• This told us integration needed to deliver
  benefits to
• Mrs Smith

6
Introducing Mrs Smith
7
Social Worker
G.P.
Practice Nurse
Domiciliary Care
District Nurse
O.T.
O.T.
Diabetologist
Family Friends
Cardiologist
8
Integrated Team
SAP
Specialist Services
Family and Friends
9
Shared vision

• Right care, right time, right place

10
Where are we now?

• Commissioning and Provider Services
• Operations
• Operate out of 17 bases across Torbay
• Range of services from community health and
  social care staff to dental, podiatry and
  specialist nurses
• 2 Community Hospitals (54 beds)
• St Edmunds (21 beds)
• St Kildas
• Total number of staff in operations 800
• Total budget in operations - 30 million

11
Where are we now?

• Zone Teams all now co-located in 5 zones
  (Torquay North, Torquay South, Paignton North,
  Paignton South and Brixham), plus two specialist
  zones provide disability/specialist services
  and public health provider services
• Brixham hospital and St Edmunds re-developed
• New community Intermediate Care Service
• Development of End of Life Care
• Focus in improvement in key performance
  indicators
• Integration of Older peoples mental health

12
(No Transcript)
13
(No Transcript)
14
Success Factors

• Agreed shared and clear vision
• Strong leadership
• Single Management Structure
• Flexibility and Autonomy
• Robust Communication Strategy
• Clear Objectives
• Co-location
• Pooled Budgets
• Patient centred focus
• Continual assessment and evaluation - Development
  of new roles (e.g. HSCC)

15
Making a difference

• For example, from this 7 stage process

To this 2 stage process
16
What is a HSCC?

• Health and Social Care Coordinators (HSCCs) are
  the first point of contact for everyone
  patients, families, carers, professionals, etc.
• One phone number to access community based
  services
• Qualified to NVQ4 Health Social Care
• HSCC takes responsibility for ensuring that we
  are doing the right thing for Mrs Smith

17
How HSCCs improve coordination

• Access to expertise and information of Social,
  Primary, Secondary Care and other organisations -
  Coordinate multi-disciplinary response to callers
• Know who are the complex, unstable and
  intermediate care cases within their zone and
  proactively coordinate their care with the MDT
• HSCCs ensure that
• All relevant information, assessments and
  investigations are carried out
• Holistic assessments and care plans are
  formulated
• HSCCs can commission services based on an initial
  assessment

18
Making a difference

• Reduction in Steps
• Referral to allocation 75 improvement within
  the first year
• Referral to assessment 66 improvement within
  first year
• Assessment to services 20 improvement within
  first year
• Improved use of skills and time
• Professionals undertake work only they can do
• HSCCs co-ordinate the holistic response for the
  patient
• Less repetition of story
• Individuals feel more valued and heard
• Ensuring all relevant information is collected
  and accurately recorded

19
Making a difference (cont)

• Reduced overhead costs (management and shared
  functions HR/Finance/IT)
• HSCCs 45 of work is one and done
• MDT co-located and integrated working reduces
  duplication and steps in the process
• Single patient/client record PARIS HE
• Reduced number of steps in the patient pathway

20
Dont just take my word for it

• Yesterday I got all the background I needed from
  the social care OT to take back direct to the
  patient. We reckoned this saved about 5 hours of
  our time (NHS OT)
• no arguments over budget responsibilitymanagers
  are now in the same building and can sort things
  out face to face (nurse)
• a nurse can just have a discussion with me and
  find a solution which prevents what would have
  been a referral (social worker)
• one phone call is all that is needed, so its a
  definite improvement (GP)
• Came back from surgery with a particular problem
  about respite after short discussion, problem
  sorted. May have taken days before (DN)
• Coming here has meant we can get to DN records
  via SPOC, or just speak to them (CCW)

21
Making a difference

• Some sample facts and figures from our OD work
• e.g. old process of Health Needs Assessment
• 16 handoffs
• 22 waste steps Vs 5 value steps
• 3 authorisations (in an ideal world)
• multiple duplications
• 2 IT systems used
• Up to 2 week delay costing potentially 800 per
  client
• New PARIS HE process 50 reduction in waste

22
The Importance of Evidence
23
(No Transcript)
24
Further Developments

• Integrated Care Organisation Pilot
• Business Process Redesign and Lean Methodology
  Evidencing Change
• Childrens Services
• Mental Health

25
Questions?