Sandwell Integrated Care Services (iCares)

Sandwell Integrated Care Services (iCares)
Ruth Williams
[email protected]
@icares_SWBH
Sandwell
Mrs Kaur has had a fall
Mr Smith has had a fall
Mr Davies has had a fall
What we do
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Long term conditions in Community
Any adult 16+ irrespective of location or diagnosis
Integrated Locality Teams , staff co-located
Single point of access with open access for life
No waiting lists
Respond to clients needs based on their view of their needs
Urgent - 3 hours
Complex - 3 days
Routine - < 15 days
• Self care and self management
• No time limit for rehabilitation but also not kept open long term
Integrated Care Services (iCares)
3 Main Functions
Admission Avoidance
Care Management
Community Rehabilitation
Pathways
Falls & Bone Health
Progressive neurology
ESD stroke
Stroke
T&O
Reablement
Elderly Frail
Head Injury
End of life care (therapy)
Intermediate Care
Own Bed Instead
Delivered by.........
The Core Team
Nurses - Community Matrons & Clinical Nurse Specialists—
Rehab, PD, MS, Progressive Neurology, Osteoporosis
Therapies—Occupational Therapy, Physiotherapy, Speech &
Language Therapists, Dietitians
Rehab support workers
Admin Team / Community Contact Centre
Home Accident Prevention Officers
Clinical Leaders
The Change Process
Demand > Capacity
Customer satisfaction
Cost saving every year
Whole service redesign
 6 month change programme
 Evidence based
(DH QIPP LTC / integration)
 Everyone involved
 Relentless focus outcomes
 Paper-free
 Model demand and capacity
 No going back
Outcomes
 7 day service for
community 8am – 8pm
 95% of clients rate the
service as 8/10+ in friends
and family test
 93% of urgent referrals
avoid admission to hospital
 Routine referrals within 11
days
 94% success in client
reported outcomes
The purpose of our work not an interruption to it
“You hear about going the extra mile, they
went an extra 200 miles”
“Don’t know where we would be without
you”
“Every goal I wanted to achieve I achieved”
“Pat yourselves on the back, you are the
best thing that ever happened to me”
“Like family walking through the door”
Staff Feedback
“It’s fantastic working in a no-nonsense, flexible service that
puts the client first” (Band 6)
“We get to see our clients when they want to see us, not when
a waiting list dictates” (Band 6)
“I have always felt supported as a band 5, not just by SLT but
by the wider team. Everyone works together” (Band 5)
“I no longer get stressed when we get an urgent referral on a
Friday afternoon” (Band 7)
“It’s about working smarter and a work life
balance not always worker harder” (Band 7)
Rehabilitation is everyone's responsibility
Make it easy for patients & staff
Wrap services around the
patient to meet their needs
Reduce hand offs
Permission to find solutions &
work together
References
Adler, J. (2009). Empowering NHS staff to drive change with Listening into Action. Health Service Journal, 28 September, 2009
Department of Health Improvement and Efficiency. (2012). Supporting the local implementation of the Year of Care Funding Model
for people with long-term conditions. Gateway Reference: 17415
Goodwin, N., Curry, N., Naylor, C., Ross, S., Duldig, W. (2010). Managing people with long-term conditions. The Kings Fund,
London.
Ham, C., Imison, C., Goodwin, N., Dixon, A., South, P. (2011). Where next for the NHS reforms? The case for integrated care. The
Kings Fund, London.
Middleton, J. (2012). A Public Health Council. Annual Report. Public Health, Oldbury. ISBN 978-1-900471-10-7
NHS Leadership Academy. (2013). The Healthcare Leadership Model, version 1.0, Leeds:
http://www.leadershipacademy.nhs.uk/discover/leadership-framework/
Oldham, J., (2012) A Guide to the Implementation of the Long Term Conditions Model of Care.
http://www.networks.nhs.uk/nhs-networks/commissioning-for-long-term-conditions/resources-from-the-ignition-phase/legacydocuments/Handbook.pdf
Oliver, D. (2014) Making Our Health and Care Systems fit for an ageing population. Kings Fund
http://www.kingsfund.org.uk/publications/making-our-health-and-care-systems-fit-ageing-population
Shaw, S., Rosen, R., Rumbold, B. (2011). What is Integrated Care? Nuffield Trust, London.
Thank You