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Rural Generic Support Worker Opportunities and Synergies. Dr Anne Hendry National Clinical Lead for Integrated Care Joint Improvement Team. Reshaping Care for Older People 10 Year Programme to 2021 £ 300 million Change Fund 32 Partnerships between

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rural generic support worker opportunities and synergies

Rural Generic Support WorkerOpportunities and Synergies

Dr Anne Hendry

National Clinical Lead for Integrated Care

Joint Improvement Team

Reshaping Care for Older People

10 Year Programme to 2021

£ 300 million Change Fund

32 Partnerships between

NHS: primary, acute, mental health

LA: social care & housing

Third and Independent sectors

Older people and carers

Change Plans signed off by all partners

Joint Commissioning Plan

Improvement Network

2020 vision
2020 Vision

Everyone is able to live longer healthier lives at home, or in a homely setting.

Integrated health and social care, a focus on prevention, anticipation and supported self management.

When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm.

Care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions.

There will be a focus on ensuring that people get back to their home or community as soon as appropriate, with minimal risk of re-admission.


Self-directed Support: in context

  • Other “crisis” interventions:
  • Homelessness
  • Criminal prosecution
  • Dealing with drug/alcohol addiction

Resource shift, over time, from crisis management and critical intervensions to prevention & “low level” support


Care / Acute



Focus on quality, build on people’s assets, professionals and citizens work collaboratively

Person-centred health care / self-management

State-funded social care

Self-directed support – choice/control for citizens

Carers & support to carers

Support, information and training to carers

Building the capacity of communities

Universal services, family, friends, community

person centred care
Person Centred Care

Community Care

Intermediate care:

Rehab and enablement

at home / care settings

Care management/

anticipatory care:

Community nursing

Primary Care:

Long term conditions

care planning

NHS Self-Management Support:

Self-management programmes/

psychological interventions

Mental Health:

Recovery support

integration purpose

To deliver nationally agreed outcomes for health and wellbeing

To improve the quality and consistency of care for patients, carers, service users and their families

To provide seamless, joined up care that enables people to stay in their homes, or another homely setting, where it is safe for them to do so

To ensure that resources are used effectively and efficiently to deliver services that meet the needs of the growing population of people with longer term and often complex needs

public bodies joint working scotland bill
Public Bodies (Joint Working) ScotlandBill

Royal Assent for legislation anticipated April 2014

Transition / shadow arrangements ongoing

Integration Plan (Scheme)

OD and workforce plans – transition funding £7 M for 2014/15

Integration Authorities from April 2015

Jointly appointed chief officer

Integrated budgets for community health and social care and some acute hospital services

Strategic commissioning plan

Locality planning

Public and professional engagement

intermediate care
Intermediate Care
  • Integrated and enabling services at times of transition
  • Alternatives to admission, early supported discharge

and support to regain independence

Time limited

  • Hospital at Home – defined specialist led service
  • Home based Rapid Response / Early Supported Discharge services
  • Bed Based - Step Up/Step Down beds in care home / community hospital
  • Reablement – service / approach

Chronic Care

  • Integrated Community Support Team
  • Community Ward