Prototyping Innovation in Place-Based Integrated Care Teams in Eastern Cheshire

The Caring Together Programme in Eastern Cheshire is a system wide approach to address the challenges of caring for the fastest aging population in North West England. Our vision of “joining up local care for all our wellbeing” is the driver for bringing together local people and professionals to co-design a new approach to care which has empowerment at its heart. An integrated care model built on the five principles below has been co-designed and tested with all key stakeholders:. Driven by the needs of the population As much care as possible to be delivered within the boundary of Eastern Cheshire Safe Sustainable Integrated In 2017, work to develop an implementation plan for the community element of the care model began. Two prototype sites were selected from the five pre-existing primary care locality areas. The work was led by the Chair of the GP Federation with the support of key stakeholders. The model is based on empowerment of people and staff with a focus on adults in the initial stages. Overarching principles for the development of community hubs: Provision of care to the registered populations in each locality. An integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care. Combined focus on personalisation of care with improvements in population health outcomes. Aligning clinical financial drivers through unified, capitated budgets with appropriate shared risks and rewards. Care professionally led, large scale change, rapid improvement methodology was adopted involving a wide range of care professionals.  Specific cohorts of the population were focussed on in each area, dependent on the individual projects chosen e.g. use of screening technology, frailty tool/assessment and compassionate communities. The high level outcomes anticipated from the place based approach included; improving patient experience, achieving greater efficiencies in the use of care resources and reducing the demand for care overall. Qualitative information suggests working relationships have been strengthened across services and this has resulted in the provision of greater integrated care. Initial data and geriatric medicine case study feedback is positive and indicates reduced GP call outs and avoided hospital attendances and admissions. The evaluation is continuing in order to measure the impact of the work. Care professional leadership and buy-in from senior managers has given “permission” for this work to take place and enabled local areas to develop needs based initiatives creating a new culture and way of working. Lead care professionals require their time to be released and work has commenced to review the roles, skills and capacity of junior roles to release the more skilled team members to expand proactive care management and rapid response. Learning from the initial prototypes will inform the future development of community hubs in the remaining localities. Key learning points: New governance and programme management approaches adopting a light touch, robust methodology are required to ensure innovation and improvement is not stifled. Identifying the objectives and outcomes from the outset is essential to measure delivery.  Ensure Care Professional Leaders are identified from the outset for each Community Hub

The Caring Together Programme in Eastern Cheshire is a system wide approach to address the challenges of caring for the fastest aging population in North West England. Our vision of "joining up local care for all our wellbeing" is the driver for bringing together local people and professionals to co-design a new approach to care which has empowerment at its heart. An integrated care model built on the five principles below has been co-designed and tested with all key stakeholders:.
Driven by the needs of the population As much care as possible to be delivered within the boundary of Eastern Cheshire Safe Sustainable Integrated In 2017, work to develop an implementation plan for the community element of the care model began. Two prototype sites were selected from the five pre-existing primary care locality areas. The work was led by the Chair of the GP Federation with the support of key stakeholders. The model is based on empowerment of people and staff with a focus on adults in the initial stages.
Overarching principles for the development of community hubs: Provision of care to the registered populations in each locality.
An integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care.
Combined focus on personalisation of care with improvements in population health outcomes.
Aligning clinical financial drivers through unified, capitated budgets with appropriate shared risks and rewards. Care professionally led, large scale change, rapid improvement methodology was adopted involving a wide range of care professionals. Specific cohorts of the population were focussed on in each area, dependent on the individual projects chosen e.g. use of screening technology, frailty tool/assessment and compassionate communities.
The high level outcomes anticipated from the place based approach included; improving patient experience, achieving greater efficiencies in the use of care resources and reducing the demand for care overall. Qualitative information suggests working relationships have been strengthened across services and this has resulted in the provision of greater integrated care.
Initial data and geriatric medicine case study feedback is positive and indicates reduced GP call outs and avoided hospital attendances and admissions. The evaluation is continuing in order to measure the impact of the work.
Care professional leadership and buy-in from senior managers has given "permission" for this work to take place and enabled local areas to develop needs based initiatives creating a new culture and way of working. Lead care professionals require their time to be released and work has commenced to review the roles, skills and capacity of junior roles to release the more skilled team members to expand proactive care management and rapid response. Learning from the initial prototypes will inform the future development of community hubs in the remaining localities.

Key learning points:
New governance and programme management approaches adopting a light touch, robust methodology are required to ensure innovation and improvement is not stifled.
Identifying the objectives and outcomes from the outset is essential to measure delivery.
Ensure Care Professional Leaders are identified from the outset for each Community Hub Keywords: place-based care; care professional leadership; health outcomes