Transforming care for older adults in Essex

The challenge Across Essex, thousands of older people receive great care every day. However, in 2019, system partners identified that sometimes older people with health and care needs were finding themselves with the wrong kind of support. In line with the national direction towards integrated care and the system’s own aspirations, partners across health and social care came together to deliver improved outcomes for residents. The Connect programme started with a system-wide comprehensive, evidence-based assessment. This involved reviewing 340 cases and 2147 acute and community beds with 95 practitioners to identify the specific opportunities for partners across health and social care to work better together to deliver improved outcomes for its residents. Ambitious, system-wide transformation Essex, alongside Newton, set about designing and implementing a programme comprising five interrelated projects all focused on achieving better outcomes for older adults in Essex - identified at system-level and delivered at place- level. 1. Admission avoidance: Aiming to reduce the number of older people admitted to an acute hospital by 11% by better connecting them to other services, including the integrated Urgent Community Response Team. 2. Discharge Outcomes: Making more independent decisions on discharge from hospital and short-term beds, aiming to enable 240 more people go home rather than to a bed every year. 3. Community Pathways: Reducing delays and length of stay in community hospitals by a target of 23%.

4. Reablement: Ensuring everyone who can benefit from reablement has the opportunity to do so, aiming to enable 1200 more people to receive the most effective intermediate care every year. 5. Supporting Independence: Improving long- term care assessments and decisions, to help a target of 1,500 people to live more independently each year. The scale of the programme and the interdependencies between these projects would enable an improvement beyond what had been achieved before, transforming the experience for people, carers, and staff. Change designed to last To ensure that Essex work together to continuously improve outcomes and maintain the sustainability of the programme, a number of principles were agreed upon that cut across all interrelated projects. These were: Better connected system partners: Multiple organisations formed unified design, delivery, and leadership teams with a common goal, prioritising collaboration and shared principles. Lead at every level: Changes were driven and co-designed by frontline teams, focusing on bottom-up improvements to connect health and care teams and enhance outcomes. Learn, develop, and grow: Throughout the programme partners upskilled the workforce for continuous improvement through training and development to ensure that all changes would be sustainable. Outcomes-focused changes: The programme implemented interconnected projects aimed at improving outcomes, with a strong emphasis on data-driven decision-making and evidence-based practices.

I think the programme’s biggest difference is its ambition. We haven’t had many programmes that work across systems like this. I think that’s the real uniqueness of the Connect programme and it keeps people at the heart of what it’s trying to do. It’s not just about efficiency, it’s about outcomes.” Nick Presmeg, Executive Director for Adult Social Care, Essex County Council

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