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Integrated Services

Integrated Services. Primary Care Team. Person. Community. Primary, Community & Continuing Care. Reform Implementation. Strictly Private & Confidential. The development of integrated person-centred care. Improved configuration and management of hospital care.

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Integrated Services

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  1. Integrated Services Primary Care Team Person Community Primary, Community& Continuing Care Reform Implementation Strictly Private & Confidential

  2. The development of integrated person-centred care. Improved configuration and management of hospital care. More proactive prevention and management of chronic illness. Greater performance management. Engagement and empowerment of staff at all levels to deliver the reform programme. HSE Reform Priorities

  3. The organisation of the totality of health and social care services provided in the community in such a way as to address the individuals assessed need at or close to home through enhanced team working and the targeting of resources to defined populations. Components of the reform include: PCCC “Transformation”

  4. Primary, Community and Continuing Care environment Primary Care Strategy

  5. Primary, Community and Continuing Care environment Mental Health Act Primary Care Strategy

  6. Primary, Community and Continuing Care environment Disability Act Mental Health Act Primary Care Strategy

  7. Primary, Community and Continuing Care environment Disability Act Mental Health Act Primary Care Strategy Childcare Act / Children’s Act

  8. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Disability Act Disability Strategy Mental Health Act Primary Care Strategy EPSN Childcare Act / Children’s Act

  9. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Disability Act Disability Strategy Mental Health Act Suicide Strategy Primary Care Strategy EPSN Childcare Act / Children’s Act Traveller Health Strategy Homeless Strategy Drugs and Alcohol Strategies

  10. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Disability Act Disability Strategy Mental Health Act Suicide Strategy Primary Care Strategy EPSN Childcare Act / Children’s Act Counselling Service SCA Traveller Health Strategy Homeless Strategy Older Persons Drugs and Alcohol Strategies Palliative Care Strategy

  11. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Criminal Law Insanity Act Disability Act Disability Strategy Mental Health Act Suicide Strategy Primary Care Strategy EPSN Childcare Act / Children’s Act Counselling Service SCA Traveller Health Strategy Homeless Strategy Older Persons Nursing Homes Act Drugs and Alcohol Strategies Palliative Care Strategy

  12. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Criminal Law Insanity Act Disability Act Disability Strategy Mental Health Act Suicide Strategy Primary Care Strategy EPSN Immunisation Childcare Act / Children’s Act Counselling Service SCA Traveller Health Strategy Cancer Strategy Homeless Strategy Older Persons Nursing Homes Act Drugs and Alcohol Strategies Palliative Care Strategy

  13. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Criminal Law Insanity Act Disability Act Disability Strategy Mental Health Act Suicide Strategy Primary Care Strategy EPSN Immunisation Childcare Act / Children’s Act Counselling Service SCA Traveller Health Strategy Cancer Strategy Homeless Strategy Older Persons Nursing Homes Act Cardiovascular Strategy Drugs and Alcohol Strategies Palliative Care Strategy

  14. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Criminal Law Insanity Act Disability Act Disability Strategy Mental Health Act Suicide Strategy Primary Care Strategy EPSN Immunisation Childcare Act / Children’s Act Counselling Service SCA Traveller Health Strategy Cancer Strategy Homeless Strategy Older Persons Nursing Homes Act Cardiovascular Strategy Drugs and Alcohol Strategies Palliative Care Strategy Schemes Modernisation Programme

  15. Primary, Community and Continuing Care environment Sectoral Plans Vision For Change Audiology Criminal Law Insanity Act Disability Act Disability Strategy Mental Health Act Suicide Strategy Primary Care Strategy Ophthalmology EPSN Immunisation Childcare Act / Children’s Act Counselling Service SCA Traveller Health Strategy Cancer Strategy Homeless Strategy Older Persons Nursing Homes Act Cardiovascular Strategy Podiatry Drugs and Alcohol Strategies Palliative Care Strategy Schemes Modernisation Programme ?????

  16. Why are we doing this? Why we need to transform primary and community care services. This focuses on the emerging health care challenges, the current shortfalls and opportunities. Where are we going? This provides a vision for the future of primary care and social services? It also highlights the benefits that will emerge for patients, clients and those providing services. How we will get there? Here we review the structures, road map and processes that have been established to implement this reform programme. This presentation looks at 3 key questions

  17. 1. Why Are We Doing This?

  18. Ireland has a unique opportunity to develop a truly world class health care system. Reasons for this include: A clear mandate to develop a community based, patient/client centered, team-based integrated health system. A single, dedicated and unified HSE. A ground swell of support from all stakeholders. Excellent and committed staff and health professionals. A wealth of experience in establishing and learning from new service models. Islands of excellence, best practice and innovation across the health system. Access to public and private funding. Time for Change

  19. There are several emerging challenges which make reform an imperative: Population Health problems such as: Obesity, Alcohol Dependency. Chronic illness Specialist provider shortages in numerous key areas. Health costs, growing faster than general inflation. Ageing population. Lifestyle and cultural challenges. Lack of integrated digital backbone. Emerging Healthcare Challenges in Ireland

  20. Current Shortfalls Varying levels of service quality across the country. Access to required health services can be both difficult and delayed. Person’s navigation is fragmented and complicated. Traditional System takes priority over patient access. No single, coherent view of Person’s needs and plan – no common ground amongst the different health professionals. Lack of cohesive working and multidisciplinary approach. Lack of trans-disciplinary approach. Undersupply of specialist services. Patchy OOH’s cover for front line and back up services. Over reliance on hospitals for non-acute needs Ineffective use of resources, wasted effort due to bottlenecks and duplicate assessment, storage and reporting. Poorly integrated infrastructure including information and measurement protocols, ICT systems. Impact Service inequities. Reduced care quality and health status. Excessive travel, due to non-local service. Person experiences disjointed and delayed services, left feeling stressed and subordinate to the system. Strained service points e.g. GP’s, A & E. Over or under utilised resources due to outmoded resource allocation. Multiple same diagnosis and administrative processes - effort diverted from the Person. Entrenched disciplines and work groups with little camaraderie. Stressed providers with reduced job satisfaction. Lack of confidence continuous criticism both externally and internally. Increased risk to persons and providers. Poor value for money, diverts resources from service improvement. Challenges in Primary care

  21. Complexity Today from Non-alignment of Providers and Population Alignment Providers and Population: Increased Simplicity - PCT Phy SW 1 GP SW 2 OT 3 PHN 4 OT 4 PHN 1 Phy PHN GP PHN 2 PHN 3 OT 2 OT 1 OT SW Overly Complex Service Organisation & Delivery GP Same GP in local community but… General Practitioner Mr. Red also needs access to SW1, OT3 and PHN3. PHN Public Health Nurse Mr. Green needs access to SW2, OT1 and PHN1. Phy Physiotherapist OT Occupational Therapist SW Social Worker

  22. Direct Referral Direct Referral and Feedback Referral Service Feedback Outdated Info & Service Flows - Bottlenecks Information and Service Flow Today - Non Integrated Local Service Information and Service Flow Tomorrow - Integrated Primary Care Team GP PHN Phy Phy PHN GP SW OT OT SW

  23. 2. Where WeWant To Go?

  24. Today: 2006 Tomorrow: 2011 Tomorrow: 2016 Self Care PCCC Hospitals Hosp. PCCC Self Care Hosp. PCCC Self Care Population Population Population No Care Requirement No Care Requirement No Care Requirement A Shift in Emphasis • Shifting the emphasis towards community care: • The diagonal arrow highlights that with the current approach people are drawn towards hospitals for services. • However with the Integrated Primary and Community Care model, the emphasis is on providing services within local communities.

  25. “To provide each person with or easy access to all services that lead to improved health and wellbeing” Aim of Primary, Continuing & Community Care: This requires multi-disciplinary Primary Care Teams focused on the same community population that will: • Identify and prioritise each persons needs. • Service the majority of peoples needs, at or close to home. • Access specialist services, at or close to home. • Provide direct access to acute hospital services and continue to guide health improvement for that persons care lifecycle Here is how it works …

  26. It is about individual people…

  27. It is about individual peopleand their families…

  28. It is about individual people and their familiesthat are part of a local community…

  29. It is about individual people and their families that are part of a community –a defined local population of 8,000 – 12,000 people… .

  30. Most of their primary and social care needs are met by a single and local Primary Care Team (PCT)… GP PHN Phy n OT SW

  31. Most of their primary and social care needs are met by a single and local Primary Care Team (PCT)… GP PHN Phy OT SW Population A The composition of the team is driven by the needs of each defined population.

  32. Most of their primary and social care needs are met by a single and local Primary Care Team (PCT)… GP PHN MHN SLT SW Population B The composition of the team is driven by the needs of each defined population.

  33. Improved Healthcare Outcomes Population Health Quality Care Person Experience Satisfied Providers Public Confidence Value for Money Teams will have common goals based on healthcare outcomes… GP PHN Phy OT SW

  34. Teams will have common goals based on healthcare outcomes… …and shared values, e.g. trust, safety, patient priority, equity, etc. GP PHN Phy OT SW

  35. Teams will have common goals based on healthcare outcomes and shared values… GP PHN Phy OT SW …and shared standards and operating protocols such as: performance monitoring, clarity on boundaries, dedicated key workers for people, how to handle priority cases, leave cover, agreed outcome targets and review processes, quality, dissatisfaction and complaints.

  36. Teams will have core members that interact more frequently… GP PHN i.e. Weekly Meeting Agenda Phy OT SW

  37. Core Extended Teams will have core members that interact more frequently… Psy GP PHN i.e Monthly Meeting Agenda Phy Other OT SW Dtn Or as needed …and extended members less frequently or as required, but are easily accessible and fully integrated to the PCTs ‘Way of Working’.

  38. Psy GP PHN Phy Other OT SW Dtn Core Extended Teams will have core members that interact more frequently… …and extended members less frequently or as required, but are easily accessible and fully integrated to the PCTs ‘Way of Working’. These extended members are typically for specialised services, e.g. orthodontics, psychology / counsellors, addiction, etc.

  39. PCT ‘D’ PCT ‘B’ PCT ‘C’ PCT ‘E’ PCT ‘A’ An average of 5 PCTs make up a network – a Primary and Social Care Network (PSCN) – serving a wider but related population of 30,000 to 50,000 people… Primary & Social Care Network

  40. PCT ‘D’ PCT ‘B’ PCT ‘C’ PCT ‘E’ PCT ‘A’ Core Extended An average of 5 PCTs make up a network – a Primary and Social Care Network (PSCN) – serving a wider but related population of 30,000 to 50,000 people… Primary & Social Care Network PCTs in a network are integrated with one another and support each other.

  41. PCT ‘D’ PCT ‘B’ PCT ‘C’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help Core • Other Extended • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home… Primary & Social Care Network

  42. PCT ‘D’ PCT ‘C’ PCT ‘B’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home… Integrated Services Hospitals Primary & Social Care Network PCTs and PSCNs are integrated with hospitals…

  43. PCT ‘D’ PCT ‘C’ PCT ‘B’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home… Integrated Services Hospitals • Local Primary & Social Care Network PCTs and PSCNs are integrated with hospitalsat the local…

  44. PCT ‘D’ PCT ‘C’ PCT ‘B’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home Integrated Services Hospitals • Local Primary & Social Care Network • Area PCTs and PCSNs are integrated with hospitals at the localand area level…

  45. PCT ‘D’ PCT ‘C’ PCT ‘B’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home Integrated Services Hospitals • Local Primary & Social Care Network • Area PCTs and PSCNs are integrated with hospitals at the local and area leveland with specialised hospitals. • Specialist

  46. PCT ‘D’ PCT ‘B’ PCT ‘C’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home… Integrated Services Multi Agencies Hospitals • Local Primary & Social Care Network • Area PCTs and PSCNs are integrated with multi agencies… • Specialist

  47. PCT ‘D’ PCT ‘B’ PCT ‘C’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home… Integrated Services Multi Agencies Hospitals • Private • Providers • Local Primary & Social Care Network • Area PCTs and PSCNs are integrated with multi agencies, private providers… • Specialist

  48. PCT ‘D’ PCT ‘B’ PCT ‘C’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home… Integrated Services Multi Agencies Hospitals • Private • Providers • Local Primary & Social Care Network • Area • Voluntary PCTs and PSCNs are integrated with multi agencies at the private providers, voluntary agencies and • Specialist

  49. PCT ‘D’ PCT ‘B’ PCT ‘C’ PCT ‘E’ PCT ‘A’ • Child Protection • Counselling • Orthodontics • Dietetics • Psychiatry • Home • Help • Other • Alternative • Care PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home… Integrated Services Multi Agencies Hospitals • Private • Providers • Local Primary & Social Care Network • Area • Voluntary PCTs and PSCNs are integrated with multi agencies at the private providers, voluntary agenciesand with support groups. • Support • Groups • Specialist

  50. At the Core ofPCCC Reform:the Person!Our Core Principles…..

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