Integrated Care Services (iCares). Transforming and Integrating Community Services within admission avoidance, care management and community rehabilitation services

NICE Shared Learning Database

Sandwell and West Birmingham Hospitals NHS Trust

This summary highlights outcomes from implementation of an integrated care service, a single point of access for service users with long term conditions. It demonstrates how key recommendations from NICE’s guideline for intermediate care (NG74) can be delivered in practice.

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Reducing delayed transfers of care over winter

NHS Improvement has written to the chief executives of all trusts providing community services setting out actions they must implement to reduce delayed transfers of care over winter. | NHS Improvement | HSJ

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NHS Improvement  chief executive Jim Mackey has said trusts must help improve delayed discharges over winter and listed six actions they need to carry out in the next six months:

  1. Facilitate the sharing of patient data with acute and social care partners and from 7 November ensure daily situation reports are completed “to enable better understanding of community services at a national level”.
  2. Jointly assess discharge pathways with local partners including “being an active participant in the local acute provider’s discharge and hosting operational discussions daily where necessary to discharge patients in community settings”.
  3. Develop “discharges hubs” over the next six months and beyond, designed to be a single point of access for patients moving between acute and community services.
  4. Ensure a “robust patient choice policy” is implemented.
  5. Clarify to partner organisations what services the trust offers to patients.
  6. Ensure collection of patient flow data and data on plans to improve patient flow.

Full detail is given by NHS Improvement who have produced the following  report to help improve flow into and out of community health services:

Flow in providers of community health services: good practice guidance

Related HSJ article: Trust chiefs given new instructions to tackle winter DTOCs

Implementing a people powered approach to health

This report gathers a wide range of insights taken from three community sites on how to implement a people powered approach to health and wellbeing.

These three main insights were found to be the most important to making a difference on the ground:

  • Helping people help themselves
  • Creating opportunities for people to help one another
  • Creating value between the professional and social spheres – helping health and care

Mobilising Communities was a short, experimental programme aimed at exploring the practical applications of the idea of ‘social movements’ in health in three communities in England.

The objective of the programme was to work with three sites to explore the opportunities to support effective ways of combining people power and community resources, together with publicly funded services, for better health outcomes across local communities.

The report goes into detail on how each of the three insights above can be developed to support a social movement in health for people and communities.

Download the full report: Mobilising Communities: Insights on Community Action for Health and Wellbeing 

Self-care: everybody’s talking about it

Self-care everybody’s talking about it
A discussion paper by Self Help UK on behalf of Regional Voices

This paper highlights the need to support patients to better manage their own health and the need for greater recognition of the potential for voluntary and community services contribution towards this. The discussion paper outlines the benefits of promoting self-care approaches and the briefing for the voluntary and community sector contains case studies.

Total transformation of care and support

The Social Care Institute for Excellence has published Creating the five year forward view for social care: how transformed and integrated health and care could improve outcomes and cost-effectiveness.

This updated paper explores the potential for scaling up the most promising examples of care, support and community health services, initially using data from Birmingham City Council, modelling their outcomes and costs.  Originally published in November 2016, it has been updated to include additional models.

The report contains the following chapters:

Vision for transformed care: Re-shaping services around the needs and strengths of individuals, families and communities.

Key messages and summary: Outcomes can be improved, and costs reduced, if the sector scales up promising practice.

Case studies: Six models of care and their potential impact on costs and outcomes.

Models of care: Overview of promising practice that support transformative change in health and social care.

Conclusions and next steps

The paper is available to download here

Transforming community care with digital technologies

Chris Gregory, head of clinical systems for LGSS Local Health and Care Shared Service explains how mobile solutions are transforming the work of community-based health teams | NHE

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As the IT provider to Northamptonshire Healthcare NHS FT, LGSS has been involved in delivering mobile working solutions to a number of community-based health teams, including health visitors and district nurses, and for providing similar solutions in local government.

The trend towards delivering care closer to home to meet both patient aspirations, and the need to deliver savings through the reduction of estate, means that increasing levels of flexible working are being demanded across the NHS. If done successfully, mobile working can help to deliver the type of service that patients tell us they would like from their health service.

As with many IT services we’ve had a few attempts at delivering practical mobile working solutions, each based on and constrained by the technology available at the time. Prior to our latest deployment, we asked staff what they needed from a mobile device. Overwhelmingly, those who responded wanted:

  • A small form factor: There is plenty of other equipment a district nurse needs to carry so devices need to be small, as light as possible and certainly no more awkward to carry than the files of paper notes previously used
  • Sufficient battery life to get through an entire working day
  • A fast start-up: Ensuring that as little of the precious contact time with the patient was spent waiting for the technology
  • Versatility: Multiple means of inputting data, suggesting the need for both touchscreen and keyboard input

Read the full article here

Cost-effectiveness of Collaborative Care for Adolescents With Depression in Primary Care

Wright, D.R. et al. (2016) JAMA Pediatrics. 170(11) pp. 1048-1054

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Question:  The Reaching Out to Adolescents in Distress (ROAD) collaborative care model has been found to be effective in treating adolescent major depressive disorder, but is it cost-effective?

Findings:  A randomized clinical trial conducted at 9 primary care clinics in Washington State suggests that collaborative care results in an increase of 0.04 quality-adjusted life-year over usual care at $883 above usual care, for a mean incremental cost-effectiveness ratio of $18 239 per quality-adjusted life-year gained.

Meaning:  Even by the most conservative standards, the ROAD collaborative care model is a cost-effective approach for treating adolescent depression.

Read the abstract here