AGM 2015 AGM Thursday, 3 September Excellent care at the heart of the community
AGM 2015 AGM 2015 Chair Sue Sjuve
Programme Welcome Chair, Sue Sjuve Our year of achievement and success Chief executive, Paula Head Annual report and strategic report 2014/15 and annual accounts Executive director of finance, facilities and estates, Jonathan Reid Presentations • Proactive Care and Frailty/Homelessness • Healthy Child Programme Closing remarks
AGM 2015 Our year of achievement and success Chief executive Paula Head
Spring ‘Thank you’ volunteers Caring for carers Developing our leaders
Summer Investing in our future More health visiting New MSK contract
Autumn A top place to work Care environments amongst the best Proactive care
Winter We’re GOOD! Most improved Best for breastfeeding
CQC result
Winter Time to Talk success Innovate to succeed Good staff survey results
AGM 2015 Annual Report and Strategic Report & Annual Accounts 2014/15 Executive director of finance, facilities & estates Jonathan Reid
Highlights 14/15 Delivered all financial targets including £1m surplus – 0.5 per cent of turnover. Another difficult year for operational staff.
Annual accounts Stewardship of public funds is a key responsibility of the board. The annual report and strategic report demonstrates what we do with the resources given to us each year and how we deliver our vision and values. The summary financial statements are a summary of the full accounts. Full accounts are available from our website: www.sussexcommunity.nhs.uk/reports Clear audit opinion was provided by the Audit Commission.
Looking forward Significant challenge for this financial year and future years. Plan to increase surplus to 1 per cent of turnover, whilst maintaining investment in clinical, community-based services. Building on continued successful delivery of service, quality improvement and financial stability we remain well placed to respond to the challenging local and national health environment, with a focus to provide more care out of hospital and in the community.
AGM 2015 Chair Sue Sjuve Adopt 2014/15: • Annual Report & Strategic Report • Annual Accounts
Proactive Care Transformational Change – Adult Services Sean Cemm Clinical Nurse Manager
Why transformational change? • Segregated care provided in silos. • Demographic shift to an ageing population. • Healthy life expectancy not growing as fast as life expectancy. • Pressure on acute hospitals – increased visits to A&E. • Need to shift more care into the community. • GPs to “ keywork ” elderly and vulnerable patients. “ I can plan my care with people who work together to understand me and my carers, give me control, and bring together services to achieve the outcomes important to me.” “I am now able to sit in the garden and see the butterflies.”
Vision for Proactive Care The vision – 2012 • An efficient, joined-up collaborative health and social care system pioneering a new way of working. • Working with patients, carers and their families. • Patients at the heart of decision making. • In control of their own care where possible. • Shared vision across partner organisations. • Ability to inspire and realise the “burning ambition” of self care.
Proactive Care partners Social Mental Physio RAIT Workers Health OT Acute Proactive Care MDT PaC MDT V Sector Carers P GPs Nursing ICT Housing Secamb Fire CCG
Benefits • Keeps people well in their own homes where possible for longer. • Reduces pressure on acute hospitals, GPs, ambulance and community. • Improves experience: patients, carers, families and professionals.
How it works Proactive care. Risk stratification. Self care self-management. Integrated teams. Case management approach.
Caring for people with complex needs Personalised, Proactive, Proportionate Goal for Mr Wilson – every moment counts Mr Wilson is frail and has complex health • Quality of life – this is the most important priority for him and his carers. and care needs. He has had several • Plan for a good death – he is likely to be in the last 2 years of life so it’s important that his admissions to hospital recently and is known affairs are in order and he has made informed decisions about the end of his life. Most • Minimise length of stay in hospital – he is unlikely to avoid some admissions to hospital so to multiple health and care teams. getting him back home as soon as possible is the priority. frail • Proportionate medical management – he needs his treatment and medicines reviewed and anything stopped that isn’t necessary. 2% Goal for Mrs Smith – plan ahead and be prepared Mrs Smith has health and care needs. She is likely to be • Quality of life – a bespoke approach to her and her carers, planning around seeing her GP and community team what matters most to her. regularly and be on multiple • Care co-ordination – she and her carers have one person they can rely on. • Care planning – she and her carers have a plan to stay happy and well, and medication. She copes but minimal she knows what to do if she is poorly. disruption e.g. a UTI or an unwell • Holistic medical management – her health is managed in line with her goals. Coping • Less ad-hoc use of services – she has regular, planned reviews with carer tips her quickly into crisis. someone who knows her and may not need active support in-between. complex Mrs Smith may be deteriorating and at risk of admission when: Goal for Mrs Smith if she deteriorates – services • Her ad-hoc use of services increases. mobilise to provide extra support in a planned • There are cries for help from her carers. 10% way • She is not coping with activities of daily life. Goal for Mr Cooper – in control of his condition and care Mr Cooper is well and • Quality of life – his condition is part of his life and independent. He has a not dominating it. • Skills and tools to self care – he knows how to long-term condition or Living well with a look after himself. care need that is under • Optimal medical care – he works together with his long-term condition or care need control and visits medical team to keep his condition well controlled and to stop it progressing. services for • Signposting – he knows what other agencies and Planned follow ups community services are available to support him. e.g. diabetic clinic. 30% Everyone else Goal – staying happy, healthy and active
Proactive Care in Coastal West Sussex • Proactively identifying and supporting frail/elderly people and their carers to prevent deterioration. • Admission avoidance. • Supporting primary care through case management and care coordination – enabling patients to adopt a self care/self-management process. • Personalised care plans with contingency. • Communication systems.
Contingency plans Coastal Proactive Care – contingency plans (year to date) 6000 5441 5199 4946 5000 4616 5343 4371 5097 4133 4848 Contingency plans 3886 4000 4529 3624 3458 4283 3274 4066 3820 2967 3000 3432 3463 3253 2340 Contingency Plans 2900 Contingency Plans On IBIS 2000 2281 1000 0 Month 98% of contingency plans are on IBIS
SECAmb data Matches and Patients by CCG 1 Jul 2015 00:00:00 - 31 Jul 2015 23:59:59 CCG Name Patients 999 Call Conveyed Non- IBIS Calls Per Conveyances Admissions Matches conveyed Conveyance Patient Ratio Avoided Avoided Rate 2 0 0 0 0.00% 0.00 0.00 0.00 886 66 28 38 42.42% 0.07 16.22 5.35 597 271 60 211 22.14% 0.45 121.57 40.12 1392 166 61 105 36.75% 0.12 50.22 16.57 NHS Coastal West Sussex CCG 6,364 1050 353 697 33.62% 0.16 350.50 115.67 NHS Crawley CCG 727 105 48 57 45.71% 0.14 22.35 7.38 1348 124 45 79 36.29% 0.09 38.08 12.57 705 94 39 55 41.49% 0.13 23.98 7.91 2344 205 65 140 31.71% 0.09 72.35 23.88 677 195 56 139 28.72% 0.29 74.65 24.63 3485 338 132 206 39.05% 0.10 94.46 31.17 17 2 1 1 50.00% 0.12 0.34 0.11 385 50 21 29 42.00% 0.13 12.50 4.13 NHS Horsham & Mid Sussex CCG 1,952 248 109 139 43.95% 0.13 57.16 18.86 396 28 16 12 57.14% 0.07 2.76 0.91 379 36 17 19 47.22% 0.09 7.12 2.35 5270 553 276 277 49.91% 0.10 94.51 31.19 483 95 43 52 45.26% 0.20 20.65 6.81 1040 76 25 51 32.89% 0.07 25.92 8.55 77 26 12 14 46.15% 0.34 5.42 1.79 430 50 14 36 28.00% 0.12 19.50 6.44 202 18 11 7 61.11% 0.09 1.06 0.35 676 192 45 147 23.44% 0.28 83.64 27.60 11 0 0 0 0.00% 0.00 0.00 0.00 21 0 0 0 0.00% 0.00 0.00 0.00 11 0 0 0 0.00% 0.00 0.00 0.00 12 0 0 0 0.00% 0.00 0.00 0.00 2 0 0 0 0.00% 0.00 0.00 0.00 15 0 0 0 0.00% 0.00 0.00 0.00 8 0 0 0 0.00% 0.00 0.00 0.00 27 0 0 0 0.00% 0.00 0.00 0.00 1 0 0 0 0.00% 0.00 0.00 0.00 1 0 0 0 0.00% 0.00 0.00 0.00 1 0 0 0 0.00% 0.00 0.00 0.00 1 0 0 0 0.00% 0.00 0.00 0.00 1 0 0 0 0.00% 0.00 0.00 0.00 109 2 1 1 50.00% 0.02 0.34 0.11 1 0 0 0 0.00% 0.00 0.00 0.00 1 0 0 0 0.00% 0.00 0.00 0.00 Report Totals: 30057 3990 1478 2512 37.04% 0.13 1195.30 394.45
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