Bernadette Elder – Inspiring Communities Together

Inspiring Communities TogetherNeighbourhood based charity

• Membership led – Trustees elected through membership • Delivers activity – learning and volunteering• Facilitates – bring people together through two local forums• Advocate – link between agencies and local community• Securing resources – paid work linked to aims

Strategic Context

3

Salford Together Partnership• Four high performing partners –

within broader network of partners• £98M Pooled Budget - Integrated

Care for Older People (ICP)• Governed by Alliance Contract• Underpinned by 2014-18 Service

and Financial plan (inc. BCF)• Formal Programme Management

approach (ICP)• ICP one of three major

transformation initiatives- Out of hospital Care (primary care investment, renewal) & HT

Salford care economy• Urban area in Greater Manchester• Population of circa 230,000• Area of significant deprivation

and health inequalities• Largely co-terminus

- Salford CGG (health commissioner)- Salford Royal (acute and community healthcare provider)- Salford City Council (adult social care)- Greater Manchester West (mental health provider)

• Long history of successful partnership working

Over view of Salford• Total population is 236,000• Eight neighbourhoods• Although there are diverse levels of affluence, Salford

is ranked as one of the most deprived local authority areas in England with life expectancy lower than the England average

• Population of people aged 65 and over is 35,000 • Number of older people is forecast to rise by 28% by

2030

5

“Integrated health and social care for older people has demonstrated the potential to decrease hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning”Curry and Ham, Clinical and Service Integration – The Route to Improved OutcomesKing’s Fund, 2010

High levels of need

National and international evidence

Significant populationgrowth

Significant cost of care

Poor experience of care

Service duplication

The Start of this Journey…

Salford’s Integrated Care Programme

Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support

3

Local community assets enable older people to remain independent, with greater confidence to manage their own care

1

Centre of Contactacts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring

2

1

Promoting independence for older people Better health and social

care outcomes Improved experience for

services users and carers Reduced health and

social care costs32

Housing Workstream

Wellbeing Plan

Care Plan

Independence Plan

SupportedIndependence

Plan

SHARED CARE PLANS

POPULATION STRATIFICATION

STANDARDS

Care Home standards

Home care and intermediate

care standards

GP standards

Carer support and disease

management

Able Sally 71%: c. 24,850

Needs Some Help 17%: c.6,000

Needs More Help 9%: c.3100

Needs A Lot Of Help 3%: c.1050

Sally’s standards

7

Making it easier to find

the right support/help and how to look after yourself at

home safely

Helping mature persons know what

help/support there is

Everyone working together so mature

persons feel happy and well

Keeping mature persons safe by staying involved

in the community

• Knowing what is in the neighbourhood• Knowing how to find out about what

is in the neighbourhood• Knowing how to use what is in the

neighbourhood

• Giving information and advice on how to look after yourself so mature persons can be happy and well

• Keeping mature persons out of hospital• Keeping mature persons happy and

healthy at home

Aim Primary Drivers Secondary Drivers

Integrated Care Programme – plain English version

2020 targets – what and why?Emergency admissions and readmissions• 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn) • Reduce readmissions from baseline • Cash-ability will be effected by a variety of factors

Permanent admissions to residential and nursing care• 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn) • Savings directly cashable but need to be offset by cost of alternative care (especially

increased domiciliary care)

Quality of Life, Managing own Condition, Satisfaction• Maintain or improve position in upper quartile for global measures• Use of a variety of individual reported outcome measures

Flu vaccine uptake for Older People• Increase flu uptake rate to 85% (from baseline of 77.2%)

Proportion of Older People that are able to die at home• Increase to 50% (from baseline of 41%)

9

Community Asset model“Using the knowledge and life experiences of older people to make life better by

listening to and valuing their views: making sure this influences services to be better in future by building on community strengths. This will keep older people

in Salford healthy, happy and independent for longer”

Engagement• The Citizen Reference Group (CRG) This formal structure was established

as part of the ICP programme. The group of local older people are supported through a development worker and meet monthly to look at aspects of the programme – acting as a critical friend. Members engage with areas of work which interest them and act as ambassadors for the programme by sharing key messages from the programme with their own networks.

• The community asset work stream project group have engaged with older people through the network of partners who attend the monthly meetings (housing providers, development workers, third sector organisations, health workers and Salford City Council). Older people are invited to take part in workshops and focus groups to understand what is important to them to support their own health and well being.

Community asset model• An Age Friendly City – the commitment of the city to

support older people to stay healthy and well. • Older Person Standards and Well Being Plans- the

commitment by older people to support their own health and well being.

• A set of tools developed by and for older people based in local neighbourhoods – the commitment of community and deliverers to support older people to stay healthy and well

Community asset work stream project groupThe network includes a wide range of partners including mature people, City Council , University, Businesses, Charities, Social Enterprises, and Third Sector, Work across a number of areas including housing, volunteering, befriending and Leisure and Health Improvement connections.

Community asset approach• Ensure there is access to advice and guidance for

older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being

• Ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity

• Developing technology as a tool for improved health and well being

• Building volunteering as a life choice in older age and linking to the centre of contact and community connectors model

• Joining up what is already happening

Cost and value to the NHS• Loneliness = £ to some one who smokes 15

cigarettes a day • Falls = over 4 million NHS bed days each year • 14% (nearly 5000) of people aged 65 and over may

be at risk of malnutrition (using BAPEN prevalence tool)

• Bad oral health leads to poor levels of nutrition & can lead to social isolation

• Technology can be a means to enable older people to renew and develop social contacts and engage actively in their communities.

Social

IsolationLonelinessDepression

Not eating

well

Not engage

d

Lack of

access to information

Limited

physical

activity

Community asset tools

Prevention and well beingOral health

MalnutritionStep up

Tech and tea

Neighbourhood activity and fund

VolunteeringCommunity connectors

Well being plans

Reduce impact

ofSocial

isolationdepressi

on lonelines

s

•Reduce emergency admissions•Improved quality of life for users and carers•Increase the proportion of people that feel supported to manage own condition

BarriersImprovement measures

The model in action

Community asset tools = £500,000• Asset mapping – development support to understand

what we have and identify gaps and opportunities• Prevention and well being – Step up programme and

advice and guidance including development of tools with older people

• Neighbourhood activity - funding to support access to activity at a neighbourhood level and support new activity

• Technology – tech and tea across the city as a tool for improved health and well being

• Volunteering as a life choice in older ageDelivered by 3rd sector in the community

to support activity already being delivered

Prevention and well being• Step up• Malnutrition• Oral health• Campaigns and events

Salford - National Pilot Site

Raising awareness Working together

Identifying malnutrition Personalised care, support and treatment

Monitoring and evaluating

Working togetherhttp://www.nhselect2.org.uk/malnutrition/salford.php

Neighbourhood activity and fund• Well being plans• Increase in volunteers• Increase in people accessing neighbourhood activity

The Salford Wellbeing Plan

Technology• Tech and tea• Digital Champions• Intergenerational• Improved local access

Tech and tea Tech and tea engages older people in understanding the benefits of technology in helping them to: • engage in neighbourhood activity • reduce social isolation and loneliness • improve health and well being outcomesThe benefits• Learning new things – how to surf the web• Keeping in touch – contacting family and friends• Improving health and well being – access to information• Reducing social isolation and loneliness – meeting new friends- http://

communityreporter.net/videos/tech-and-tea-2015

Helping each other – giving time

Volunteering Formal - Volunteer coordination to develop a network of volunteers and provide support • Volunteers in care homes pilot• Well Being Champions• Digital ChampionsInformal – Community connectors – delivered through Age UK Salford. Encouraging and supporting people to knock onNeighbourhood groups – volunteering for each other

What it means to people in Salford• Increased public awareness that losing weight, bad oral

health and being lonely are not a natural part of ageing• More older people equipped with tools to self manage their

own health and well being• More neighbourhood assets have access to information and

tools to support older people to manage their own health and well being

• More neighbourhood assets are better equipped to detect early signs and know how to provide advice and guidance to older people

• Easier access to activity and written information for older people to help them manage their own health and well being

Meeting the targetsImprovement measures: • Technology as a tool to increase the proportion of older people that feel

able to manage their own long term condition and improve the quality of life for users and carers

• Prevention and well being activity ensuring there is access to activity, advice and guidance for older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being. This will help reduce emergency admissions and readmissions.

• Neighbourhood activity ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity to increase the proportion of older people that feel able to manage their own long term condition and improve the quality of life for users and carers

Moving from health to well beingMedical model• Hospital to home – Salford Home Safe• In own home –

– Multi Disciplinary Groups (MDG)– Centre of Contact– GP Surgery

Asset based model• Building on individual strengths• Using the right tools – well being plan• Setting personal goals• Joining up what is already happening and flipping the axis to

support the best outcomes for the person as safely and as quickly as possible

Demonstrating the difference

Quality improvement: • A test and learn approach – Small scale test and rapid scale up based on

evidence – dash board of measurers:• Loneliness tool• Well being plans• Digital skills• Increase in volunteers• increased community resilience• Improved level of fitness measurers• Increase in awareness of eating well in later life quizHigh level evaluation - CLASSIC: • Improved quality of life measurers

Home

CA coordination

group

Medical support

Community assets

Person ill at home

WellbeingPlan

Reconnecting individuals to the community

Centre of

Contact

Home Safe

Ready to manage

own health

Home support• Care on call• Health Trainers• Befriending• housing

Hand holding

• Well being coaches

Sign posting• Health Improvement• Neighbourhood

management

Confidence bld

MDG

GP surgery

Opportunities and challengesOpportunities:• Community Asset approach recognised as part of the solution• Budget allocation – Lowest % at present• Starting to demonstrate impact = £££• VCS as partners in coproduction of modelChallenges:• Moving funding outside the system• VCS working in partnership – Salford approach 3SC (86

members)• Large contracts V small scale neighbourhood interventions

Thank you for listening – For further information

http://www.salfordtogether.comhttp://inspiringcommunitiestogether.co.uk bernadette@inspiringcommunitiestogether.co.uk