Brent Integrated Care Coordination Service

1
Brent Integrated Care Co-ordination Service

• Funded through the DH
• Partnerships for Older People Project

2
POPP is about

• Both
• Prevention of inappropriate admission to
  hospital or residential care
• Improvement in experience of community services
  and in quality of life
• And
• Whole system change towards these

3
Integrated Care Co-ordination Service

• 10 care co-ordinators who assess and link people
  into appropriate services across health and
  social care economy
• Specialist mental health and housing support
  workers
• Practical partnerships for befriending, small
  repairs, benefits advice

4
ICCS

• Built on existing team at Willesden hospital
• Organised broadly in line with GP localities - 2
  care co-ordinators per cluster
• GP referrals
• Links with AE at Central Middlesex
• Links with screening in Social Care Older
  Peoples Services

5
Who can benefit from the service?

• People over 65 who may
• have had several unplanned hospital admissions or
  AE attendances
• be experiencing major changes and have little or
  no support
• consistently miss hospital or GP appointments
• do not reach the Critical/Substantial criteria
  for social services support and do not have an
  allocated care manager.

6
What do we do?

• Assess (using SAP) and co-ordinate services
  around individuals for a planned (8-12 weeks)
  period
• Identify needs holistically and ensure services
  are engaged to meet them
• Work with individuals to identify their own goals
  and solutions
• Support, encourage and facilitate engagement with
  services

7
Case Finding

• Case finding with GPs - EARLI questionnaire
• Links with AE at Central Middlesex
• Links with screening in Older Peoples Services
• Links with Brent Rehab Service, Community Matrons
  and District Nurses

8
Achievements

• Single, holistic assessment and facilitating
  access to range of support
• Joint IT system - improving communication across
  health and social care
• Innovative elements
• Emunity website
• TOYL befrienders
• DWP Age Concern partnership

9
Outcomes

• 334 people provided with CC support
• Elders Voice handyperson - 182 pieces of work
• Housing Advice worker - 38 people
• TOYL - 6 matches
• Mental Health Nurse - 26 people
• OT/Trusted Assessor - 17 people in March
• Voluntary and community services
• Informal care supported

10
Challenges

• Risk of PCT withdrawing funding from team
• Lack of engagement due to Turnaround process
• How to identify and realise any cashable savings
• Complexities of joint working
• Not enough time to demonstrate effectiveness

11
Key Learning Points

• Everything takes longer than anticipated - even
  when you anticipated it would
• Almost everything is more complex and difficult
  to solve than anticipated
• Need the capacity to recognise difference,
  interpret language and systems and take nothing
  for granted

12
Other Learning

• Outcomes are based on whole system activity and
  involvement
• Savings cant be individually allocated
• Must take a whole system approach - but what that
  really means probably needs to be thrashed out
  locally
• Shared systems make and enormous difference to
  efficiency, cost effectiveness and quality of care

13
And more learning

• Do whats possible - small wins are important
• Targeting is critical to successful outcomes -
  right professional taking responsibility at right
  time
• A case management approach works
• Older people value individual relationships and
  one point of contact