Integrating Health and Social Care: blending services, processes, technologies and

Integrating Health and Social Care:

blending services, processes, technologies and information in partnerships

Dr. Elena Beratarbide, PhD, MeHealth, IEng, BComp, BBA, CISA, DPO Information Governance & Security Lead, eHealth, NHS Fife

IG Policy Advisor, Scottish Government , eHealth Division

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75+ LTC Co-morbidity Complex needs

In 20 years HSC expenditure

70% 

The challenge

90

% 70

% 50

% 35

% 22

% 11

% 8% 4%

By 2033 75+

60%  31% to 40%

9% 

8+

…

5 4

3

2

1

2020 Vision

Safe, effective and person-centred care which supports people to live as long as possible at home or in a homely setting.

http://www.gov.scot

A Route Map to the 2020 Vision for Health and Social Care

https://www.yout ube.com/watch?v

=3Fd-S66Nqio

H&SCI

Momentum

Unsustainable system

Strategic setting

2020 VISION

Instrumental setting Legislative

&

regulatory setting Information

and IT setting

+ 32 Community Planning Partnerships + 32 Councils

+ 14 NHS Boards

How IAs are structured

Corporate Body Lead Agency

NHS Boards and Councils delegate H&SC functions to an IJB (Integration Joint Board) The Act allows partners to work jointly.

NHS Boards and Councils delegate some of their H&SC functions to each other.

The carrying out of functions is overseen by and IJ Monitoring Committee.

Scottish Ministers Scottish Parliament Electorate

www.audit-scotland.gov.uk

Funding to Support Integration

H&W outcomes

300 55%

Delayed discharges

100 18%

Telehealth 30 6%

Primary Care

60 11%

Social Care fund 51,5 10%

H&SCI funding

Scottish Government Local

Authority

NHS Board

In Million £

ADULT CARE

Services to be integrated

Adult Social Work

Community Health

Hospital (some)

nursing, physiotherapy and mental health Housing

vulnerable adults and disability adaptations Planning

Specialties with largest proportion of emergency

admissions to hospital

Local partnerships strategy (3y)

• Health of the population

• Quality of Care

• Value & sustainability

+ criminal justice social work

+ children’s health & social

care

Shaping the Future

Intelligence for H&SC Integration

Access to services: How does it look like?

Locality profiling Delayed discharge

problem

Pathways High Resource

Individuals LTCs & Disability

Palliative and End of Life care

services

Dementia Post Diagnosis

Support

Unscheduled care, impact on

DD and costs

• Partnership &

Localities views

• What are the priorities ?

• What has to be changed? Co-

redesign of services, processes and

pathways

Resource Use - Partnership Overview

Health & Social Care Users

Health Only Users

Social Care Only Users

All Users

per 4.4k

30.1m

£6.9k

per 78.7k

77.4m

£1k

per

373 1.4m

£3.8k per

83.4k

108.9m

£

1.3k

1

2

3

Key points/insights

1

There are 83.4k health and social care (H&SC) users in the area . These users consume almost £109m of H&SC resource which equates to approx £1.3k per service user

2

Service users with health only contact make up the majority of users (94% - 78.7k) and consume the majority of resource (71% - £77.4m).

Those who have contact with both health & social care make up only 5% (4.4k) of all service users but consume 28% (£30.1m) of resource. This equates to £6.9k per user.

3

Resource Use - Locality View

East Key points/insights

per

1.7k 11.2m

£6.5k

1

The majority of all service users are from the West locality (62%). Cost per user is very similar across localities with £1.3k per user in the West compared to £1.2k in the East.

per

30k 28.3m

£0.9k

per

0.1k

137k

£1.4k

Health &

Social Care

Health Only

Social Care Only

West

All Users

per 32k

£1.2k 39.6m

per 51.3k

£1.3k 66.9m

per

2.6k 17.6m

£6.8k

per

48.6k 49.1m

£1k

per

0.1k

141k

£1.2k

1

2

In terms of comparisons between the localities across the different user groups, costs per client are very similar.

High levels of

variation

between

localities ?

Users of both Health and Social Care Locality View

Number of Users Key points/insights

1

East West

Cost Per User Total Costs (000s)

The distribution of users and total costs is very similar across the localities.

2

Cost per user aged under 65 is higher in the West locality, with the West costing approximately

£500 per user higher in the West. Males cost more per user in both localities.

3

Interestingly females aged 65+

cost more than males per user in the West locality but this is reversed in the East.

4

Males over aged 65 cost almost

£2k per user more in the East compared to the West. Females cost £1.5k more in the East than in the West

Users of both Health and Home Care – Locality View

Key points/insights

1 There are more users of health and home care in the West than the East. 76% of users are aged 65 and over.

1

2 The difference in use by locality (East versus West) can be seen when the number of users is normalised by local populations.

In the 65 and over age group, 1 in 15 people use health and home care in the West, compared with 1 in 20 people living in the East.

It would be good to understand this distribution in users. Are users in the West in poorer health than those in the East or is the difference linked to access to services or another reason?

2

Forward Service access insights

e.g. rural analysis highlights that individuals from more rural areas receive less social care and cost less per person but have longer

stays in hospital

It is too difficult to get there … I’ll wait and see !

Or ...?

post acute care services are not available there…

you have to stay a

bit longer here

Forward Diving deeper

(e.g. End of Life)

Forward

Cost Per Person Planned Unplanned

Acute-inpatient £4,530 £7,737

Psychiatric -inpatient £39,487 £18,914

Geriatric Long Stay £3,867 £9,498

Diving deeper

(e.g. End of Life)

Jun Aug Oct Dec 2015 Apr Jun Aug Oct Dec A&E + 22d nEL

Jun 4, 2014

A&E + 26d nEL Oct 8, 2014

A&E + 26d nEL Jan 22, 2015

A&E + 10d nEL Mar 9, 2015

A&E + 22d nEL Jul 16, 2015

A&E + 12d nEL Sep 29, 2015

A&E +48d nEL Oct 14, 2015

Care Home Dec 1, 2015

Died Dec 31, 2015

Gender Age at death Resident of LTCs

Female 88 xxTown 8

118 nEL BD @ £55,156 55 DD BD @ £13,646

Home care hours @ £16,675

Forward Diving deeper…. (e.g. HRIs)

• 2.1% of EL population

• 221 (12.7%) in care homes

• Total bed days: 1562

• Emergency bed days: 1361 (87%)

• Total hospital costs: £5,480,003

• Total residential care cost: £5,496,277

Forward

Understand the process

then co-re-desing

Forward

Intelligence led planning

INFORMATION SOURCES (e.g.)

• Housing

• Care homes and admission activity

• Primary care demand and capacity data

• HHG breakdown and pathways

• Care at home provision and variation

• Admission data linked to our integrated H@H service

• Unscheduled admission analysis and links to delayed discharge

• OOH activity

CONSIDERATIONS

• Strategic plan (your priorities)

• Service improvement

• Operational delivery

– Front line practitioners

– Resources & support – Information

Bottom-up Co-redesign You will never know it all !

Sources of intelligence:

Discovery, LIST, Source, Spire etc.

People stories What’s the

evidence, impact

and cost benefit?

Forward Work in progress & future plans...

Directions, directions, directions!

Primary care data – starting

with HRIs pathways

Role of IT – eHealth – Information Services

•Linking information (linked datasets)

•H&SC Portals

•Information Security National Framework

Individual linkage of delayed discharge information to

social care information and analysis of

social care services pre and

post hospital stay

Predictors

H&SC National Outcomes

1 People are able to look after and improve their own health and wellbeing and live in good health for longer.

2 People, including those with disabilities or long term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community.

3 People who use health and social care services have positive experiences of those services, and have their dignity respected.

4 Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services.

5 Health and social care services contribute to reducing health inequalities.

6 People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and well-being.

7 People who use health and social care services are safe from harm.

8 People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide.

9 Resources are used effectively and efficiently in the provision of health and social care services.

Outcomes Framework

http://www.gov.scot/Publications/

Lessons learnt (so far)

Momentum Who is leading? Co-redesign

Clear governance (spread it over

and over)

Intelligence planning

Measure outcomes

“integrated team” mind set

Digital preparation

Trust &

Transparency Simplify first Data quality

Share information

safely

Keep it

real

‪ @eHealthScotland

@PersonCntrdSco

@partnersforhsci

@eberatarbide

https://lnkd.in/d9Rp8uc

Thank you…

and please join the conversation

Dr. Elena Beratarbide, PhD, MeHealth, IEng, BComp, BBA, CISA, DPO Information Governance & Security Lead, eHealth, NHS Fife

IG Policy Advisor, Scottish Government , eHealth Division