Briefing paper for stakeholders -

Self Care Pilot (January 2016 – December 2016)

Background

Following the submission of a business case to WLCCG and the whole systems steering group, KCSC is being commissioned to deliver a pilot self-care programme.

We believed it was important, when making our business case, that we present a model, and a sector, capable of responding to patient need. The business case does not replace our belief in the need for grants. KCSC believes passionately that grants should be maintained and to date we have been successful in obtaining a grantfunding for the voluntary and community sector from WLCCG.

However, we also accept that some delivery requires voluntary organisations to work to different business models.

The service specification

According to the service specification:

In line with many areas of the country there has been a significant increase in non-elective activity in West London in recent years, with a high proportion of people with long term conditions over the age of 65 years admitted to hospital each year…. Self-care activities that improve anticipatory care, reduce avoidable crisis and support joined up care for vulnerable population groups are key to affecting this trend, and provide a better standard of care closer to home.

In order to deliver whole systems, Patients over the age of 65 in tiers 2 and 3 as described below will receive integrated care planning sessions at a minimum of twice a year. The sessions will take place in newly formed Integrated Care Centres, one in the north of the patch and one in the south, within the West London CCG area.

In addition to these sessions, new holistic roles have been developed to help deliver them. The case Manager will primarily support those in Tiers 2 and 3 and Health and Social Care Assistants will help support those primarily in tiers 0 & 1.

The self-care pilot will focus on delivering self-care activities via the voluntary and community sector to those patients in tiers 2 & 3 and for some in tiers one.

Long-term aim

The long term aim is to create a consistent and wide spread co-ordination of services that meet the needs of individuals attending the WL Whole Systems Integrated Care for Older Adults (WSICOA) hub. Providers will work together to effectively assess, identify risk early and quickly put in place the care and support necessary to actively avoid further deterioration and facilitate fast recovery through providing proactive assessment, care planning and reactive care support where appropriate.

The outcomes that the service should strive to achieve are:

  1. People have a high quality of life
  2. Care is safe, effective and people have a good experience
  3. Professionals experience an effective integrated environment
  4. Care is financially sustainable
  5. Care delivery is efficient

The Tiers

The process - summary

The provider process

Any provider wishing to provide, and be paid for, services will need to give KCSC details of its services and its unit costsetc by completing an on-line questionnaire.

KCSC will also need to ensure organisations have relevant governance and meet quality and governance conditions.

Providers and their services will be approved and, if accepted, KCSC will issue service level agreements to block or spot purchase services.

Steps

November 2015

Providers need to complete (or review) the service information on the questionnaire, stating what services they can provide, who to and the service cost.

KCSC and the provider will discuss and agree a service level agreement and undertake governance/quality checks.

December 2015

Agreement will be signed.

January 2016

First payments made and provider starts to take referrals

Provider services

For referral purposes and for costing purposes services will fall into three categories:

Services we might fund

Services will be based on supporting the patient to meet the goals developed with their Case Manager. These goals will work towards the long-term outcomes for the patients.

Services may contain the following:

Service list
One to one services
  • Advocacy, Peer Advocacy

  • Befriending generic or specialist

  • Advice via a home visit

  • Complementary therapy

  • Counselling or emotional support

  • Home exercise or active session

  • Home support

  • Telephone befriending or support

  • Volunteering (for health)

  • Other one to one

Group activities
  • Exercise/active activities

  • Lunch/social clubs

  • Other activity

  • Peer support group

  • Supported exercise activities

  • Other group activity

Condition specific
  • Condition specific one to one support

  • Health talks or programmes

  • Condition specific exercise

  • Other

Contact Person

Olivia Leu, Self Care Coordinator, KCSC -