1. Our plans to transform health care
delivery in Hampshire
our integrated care model
November 2009

2.  Katrina Percy – CEO, Hampshire Community Health Care
 Chris Gordon – Medical Director, Winchester and Eastleigh Healthcare
Trust
 John Hughes – Medical Director, Hampshire Community Health Care
 Sue Harriman – Director of Clinical Excellence and Delivery, Hampshire
Community Health Care

3. Hampshire Community Health Care has responsibility for delivering
Our Profile
community and out of hospital services across Hampshire
Our service portfolio and size Our Community
HCHC has an annual turnover of £135m and
employs 2300wte (3000 headcount) Serving a
Our service lines Which include these services population
Rapid Response, Patient
of 1.2 million
Adult Unscheduled Care Support Teams, community people in 16
beds, etc
Health visiting, school
localities
Child & Family Services nursing, child & adolescent across
mental health services, etc
Hampshire.
Orthopaedic Choice,
Scheduled Care diagnostics, outpatient
services
Dental Services Community dental service
Population expected to grow by 50,000 over next
Smoking cessation & other Smoking cessation, sexual 5 years, with most growth in 65+ age bands
health promotion health service, etc
Mix of very rural districts and urban conurbations;
mix of very deprived wards and some of the most
healthy & wealthy areas in England.
Particular need to focus on the growing needs of
those with long term conditions and providing
support to older people & their carers to remain
healthy and independent
3

4. Our Strategy
Our strategy to transform service delivery for people in Hampshire
An integrated health and social
care system keeping people in
Hampshire as healthy and
‘Doing what we independent as possible in
do better – and their community
proving it’ An organisation leading and
working with partners to deliver
very high quality integrated
health and social care services,
with transformational
improvements in quality,
productivity & patient experience
A healthcare provider
demonstrably delivering high
quality, effective community
services that meet patient’s needs
and make a significant
contribution towards the desired
‘Working with
outcomes of the health system others to make a
step change’
A healthcare provider with a
contract to deliver a range of
community services to patients
in Hampshire

5. Our strategy
Our strategy to transform services and transform our organisation
Our strategy to transform service We measure improvement using
delivery 10 Key Outcome Measures
Reducing unnecessary hospital
Our services will offer consistently available
credible alternatives to acute admission &
admissions
are be responsive to the needs of patients Reducing acute hospital length of stay
Rapid response to crisis (1 hour)
Leg ulcer management (heal rates)
15% better outcomes, 15% less cost through
a new model of care and delivering End of life care (place of choice of
productivity improvements death)
Access to Care for planned services
40% reduction in acute bed days for older
Smoking cessation target
people and better outcomes through Sexual Health (Chlamydia screening
integrated care partnerships rates)
Children and family services delivery
of national programme
Patient experience measure

6. Implementing Service Transformation
The bigger prize delivered through wider system change
Our aim In order to do this
Our aim is to integrate the delivery of care for In order to do this quickly, and in time to reap
patients across primary, community, acute and the rewards, we plan to develop an Integrated
social care in order to: Care system with federated groups of primary
care, community care, social care and elderly
acute care, as this will provide for us
 Generate cash-releasing efficiency
gains in the order of 30% by increasing
productivity, reducing cost and removing  A clinically led, patient centred model
duplication in community services
 A single focussed leadership accountable
 Reduce elderly admissions to acute
for delivery of these objectives (rather
hospitals by up to 40% - improving the
than a series of partnerships which rely
quality and clinical outcomes of the care
we deliver by changing the way we deliver on goodwill to deliver change)
services (eg moving hospitalised elderly  Clinical alignment around a single aim
care patients into community based virtual
 Elimination of the interfaces which
wards). Drive reduction in paediatric
attendances and admissions to acute currently prevent organisations working
together and which result in patients
 Improve the experience patients have falling between organisations
of the NHS in Hampshire, by providing
better co-ordinated care with fewer hand-  The appropriate incentives we need to
offs between providers drive change in the system

7. Implementing Service Transformation
Bringing organisations together to deliver integrated care
Re-ablement services
Social Care services Locality based systems of
Integrated Care
Geographically based
Primary Care services Older people’s In- & out-
of-hours primary care federated General Practice
integrated with community
Integrated Care Model
services, social care, older
Community Services Adult
community services
people’s medicine and parts Serving population 1m – 2m
of older peoples mental
health serving approx
100,000 people
Adult Mental health services
Local clinical leadership,
operational management and
budgetary control
Hospital services
- older people’s services, some LTC
services, discharge teams, some
urgent/unscheduled/front door services
- community paediatrics Key:
Community based
older people’s Forms part of Integrated Care Delivery Model
services
Remains in existing organisations

8. Implementing Service Transformation
Integrated Care System formed from local primary & community care services, plus
the relevant components of acute elderly, mental health & social care
Community Integrated Care
Primary Care
services budget
budget and staff System
and staff
primary, community, mental
health, social care, and relevant
Social care acute care staff work together in
Acute budget and staff the Integrated Care System to
elderly budget deliver better care for patients
and staff Mental health
budget and staff
Integrated Care System launched with budgets from each organisation and five year trajectory to reduce that funding
We need to find a simple way to make the money move round the system –
that incentivises the behaviours we want and shares risk appropriately

9. Implementing Service Transformation
For our patients this will mean significantly better quality of care – in terms of
outcomes, safety and experience
Scenario Current pathway Redesigned pathway
Referral to community based Rapid Assessment Unit via Out of Hours
Lady aged 92 in an primary care service. Overnight support from Rapid Response Team
acutely confused or family. Full assessment next day with diagnostic support. Care
Referral to A&E, patient admitted to
state, with offensive acute hospital
provision in place next day – so admission avoided. Worst case
urine, on a Sunday scenario requires short stay in community hospital bed with specialist
support and rehabilitation. Confusion settles over 3-5 days; home
evening
based rehabilitation to enable full functional recovery
Assessment at community based Rapid Assessment Unit. Patient fast
Lady aged 72 with tracked for specialist diagnostics and Speech & Language Therapy
Referral to A&E or Emergency Medical assessment. Home based rehab organised with specialist review by
weakness in left Assessment Unit at Acute Hospital Community stroke rehab team.
arm If patient does need to be admitted to hospital, the community
support team facilitate her discharge home after only 2-3 days
Complex case of Early intervention with support to manage patient’s long term
older person, Disjointed care, delivered only once condition through a programme supporting exercise, disease
patient’s mobility affected and after management and other lifestyle issues. Multi-agency co-ordinated
currently managed they are severely impacted by their approach with one care manager. Early pro-active intervention
through multiple health and social issues ensures prolonged period of healthiness, independence and self
agencies at home confidence

10. Implementing Service Transformation
Integrated Care System formed from local primary & community care services, plus
the relevant components of acute elderly, mental health & social care
Future model:
Federated GP practices and hub for primary &
Current model:
community 24/7 services, rapid assessment of
Individual GP practices
acute conditions and A&E minors, and community
paediatrics
GP GP GP GP
practice practice practice practice
GP GP GP
practice practice practice
GP GP
practice practice
GP GP GP
practice practice practice
Community hub:
Rapid Assessment, Beds,
GP GP GP Diagnostics
practice practice practice
GP GP
practice practice