WLCCG Whole Systems Integrated Care Pioneer: : The Community Living Well Service Kensington & Chelsea Social Council Health & Wellbeing Voluntary Organisations Forum 5 th July 2016
Background Introduction What is the Community Living Well Service? How the service model was developed What will be different for service users and GPs Next steps 2
Background The Community Living Well service is one of two Mental Health Whole Systems Integrated Care Pioneer Projects in NW London The Community Living Well service focuses on people with stable long term mental health needs who currently are supported within primary care It aims to create a vibrant network of support and services located in community settings which wraps around individuals with LTMHNs and their carers to enable people to maintain mental, physical and social wellbeing Support based on hope, empowerment and recovery Watchwords: Easy Access, Preventative, Pro-active, Self Efficacy: living well, not just in recovery A business case for the service was approved by the WLCCG June Governing Body- this included new funding for buildings and navigator posts 3
How we developed the Model of Care There has been extensive co-production over last two years with people with serious long term mental health needs, Carers, Local Authorities, Voluntary Sector, GPs, Secondary Clinicians and Managers, including 100 people in 2014 and a group of 24 people in 2015, of which one third were service users and carers to develop the Model of Care. On-going engagement with providers, users and carers across sector, as evidenced in Business Case. Alignment to the Like Minded Strategy 4
Support from Key Stakeholders 5
...People Places 6 The core features of the Community Living Well Model Service Easy access, pro-active, 24/7 providing full range of biopsycho-social assessment and services to support service users, their carers and GPs based on principles of empowerment and self care. Tier 0: Self help and community support Tier 1: Peer support, e.g. daily living tasks, personal budgets. Tier 2: Navigation in specialist non mental health areas e.g. benefits, housing, employment, debt. Tier 3: Primary care mental health: case management, psychiatry, psychology, counselling, diagnosis Tier 4: Specialist acute mental health: e.g. urgent care, early intervention, in-patient. Enhanced physical care support for people on SMI register with two or more LTCs Increasing health and social care needs Service users and carers empowered to help themselves and each other; active co-workers in living well. Peer support Specialist navigators GPs are central to care, and receive specialist resource to deliver Living Well Plan from CLW Co-Workers Mental Health Specialists: CMI and Stable SMI in CLW; Complex /High Risk SMI in CNWL A vibrant, resilient community-integrated network of pro-active care, support and treatment, matched to need and risk, that best secures the mental, physical and social health of those with long term mental health needs Home Community settings North / South Hubs GP practice 3 rd Sector CNWL & ASC
What this will mean for GPs and our Patients: wrap-round offer Community Spokes Self Help Integrated Health and Wellbeing Centres Case management GP Practice Peer Support Management of physical care Virtual MDT approach Service User/ Carer Psychological Therapies Navigation and Employment Support Single Care Record - SystmOne Out of Hospital Specifications for Complex Common Mental Illness and Severe Mental 7 Illness, Recovery & Staying Well Plan
Managing SLTMHN in General Practice: Now Clinical Case Case Study Description: Zoe: Now Zoe is a 45-year-old patient with bipolar disorder. She was discharged following her first admission two years ago and has been out of hospital since. She was recently discharged from secondary care back to her GP as she was stable on her medications. She takes little exercise and is clinically obese. Her physical health is poor- she is diabetic and has coronary heart disease She has recently broken up with her boyfriend and is staying with her mother. She doesn t get on with her mother well and wants to move out. She also hasn t worked for 2 years since her diagnosis and struggles to make ends meet with her benefits. She is scared to go to the job centre in case they reduce her benefits Support Pre-CLW Service Zoe is discharged back to her GP and is seen by her GP five times in the first year under the developing OOH specification She can no longer access the Recovery College and so loses contact with the social network she has built up. She can pay to access it, but can t afford to. Her GP monitors her long term conditions but Zoe has missed a number of hospital appointments and her diabetes is poorly controlled She has no on-going support for her mental health care and her GP is left alone to manage needs that feel unresolved despite her care in secondary. Zoe feels isolated, anxious and increasingly in need of support. 8
CLW: What will be different from current services? Zoe: future Future: Zoe attends a joint transition meeting between her CMHT co-ordinator and her CLW link worker Her PCLN becomes her new care co-ordinator with whom she agrees a care plan. This is shared with her GP. Her care plan is on SystmOne which means all staff involved in her care who need to access it can do so. Zoe now sees the nurse several times a year and also the GP regularly: vital support for her. As she has diabetes and coronary heart disease, she goes to the Integrated Health and Wellbeing Centre once a year where she, her GP and her care co-ordinator review her health and she is able to see a dietician and someone about her diabetes at the same visit. She then agrees changes to her care plan to cover both her physical and mental health She is also referred to an Employment Advisor who is able to improve the level of benefits she was on and get her into some training. A Navigator also helps her with her housing application. She continues to access all the Tier 0 (Self-Help & Community Support) and Tier 1 (Peer Support) support she had before. She finds out about a regular walking group she can join. A Peer Support Worker comes along and introduces her to other members of the 9 group.
Next Steps Bring together clinical and wellbeing services under a single management structure Develop the service hubs Re-focus services to the new model of care, underpinned by extensive Organisational Development and an Alliance agreement between partners Set up navigator services Accountability. Service users and carers continued governance of the new service 10
Thank you Website: www.westlondonccg.nhs.uk Email: fionasutcliffe@nhs.net