Integrated care: frequently asked questions

What is the vision of integrated care?

Our vision is to deliver effective, efficient, high quality, safe integrated care to enable the residents of Blackburn with Darwen to live longer and live better.

How has this vision been identified?

Our vision has been informed by the needs of our local population identified through ongoing needs assessment as part of our ISNA, Health and Wellbeing Strategy and both commissioner and provider plans.

How will it be achieved?

Our vision will be achieved through building a whole health and care system that:

  • Promotes self-care and resilience by building and utilising community assets and the co-production of care
  • Manages people’s needs in the community unless there is an absolute medical/care need for them to be in hospital/residential care
  • Creates integrated care in localities and preventive service teams based on GP registered populations
  • Integrates support around the needs of the individual through a personalised approach to care
  • Provides high quality evidence based holistic care, continuity of care and a named care co-ordinator for anyone with multi-morbidity and/or aged over 75.

Why is integrated care needed? What are the issues with the current system?

The current system:

  • Too many people have unnecessary hospitalisation
  • Too many stay in hospital too long
  • Too many people are discharged into long term residential care
  • Our system is complicated

What are the local challenges?

  • Aging population; significant increase in the proportion of people aged over 65, which is expected to increase from 13% to 17% by 2035 and the number of very elderly residents over 85 expected to double.
  • Diverse population; the proportion of non-white residents, predominately from Indian and Pakistani backgrounds, amongst the highest in the region.
  • High rates of morbidity and poor life expectancy; for men and women when compared nationally. The current life expectancy for both men and women in Blackburn with Darwen in 2012 is at national average levels for 2002.

What will the new system be like?

  • Less people admitted to hospital as an emergency
  • We will have individual care plans for high risk patients
  • We will focus care around the needs of the individual, through the development of 4 clinically led integrated locality teams, ensuring that services and support are wrapped around a local cluster of GPs, including community health, social care and voluntary sector
  • We will ensure that effective information, advice and support will be available at times of crisis, delivered in an integrated and systematic way – we will encourage more reliance on self-care and community provision
  • We will have an intensive home support service in place

What are the aims of this model?

Our model of care is designed to:

  • Improve people’s experience of care
  • Avoid hospital admissions
  • Reduce lengths of stay in hospital and delayed transfers of care
  • Avoid admissions to residential and nursing homes
  • Improve early diagnosis of dementia
  • Support people to live better and live longer

What difference will integrated care make to patient and service user outcomes?

By April 2020, we expect service users in Blackburn with Darwen will feel more in control and be able to take responsibility of their own care, and will understand what services are available to them. In reality this means people:

  • feel like they are dealing with one organisation and they will only have to provide personal information once
  • understand that information is shared between those involved in their care
  • have access to local teams that are familiar, communicate well and help them navigate the health and care system when they need it
  • feel like they receive support from staff who routinely “go the extra mile” to help them
  • receive the right treatment quickly without having to deal with lots of people
  • will not have to face unnecessary delays in leaving hospital
  • will not have to make life changing decisions about their future care from an acute bed
  • will have alternative support to long term residential and nursing care, through intensive support delivered in their community, wrap around support and alternative housing availability
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