Most importantly, we patients prefer and hope to

Most importantly, we patients prefer and hope to

Most importantly, we patients prefer and hope to be at home not in hospital, so I think this service is the way of the future. HomeFirst I felt I was looked after at home much better than I would have been in hospital where I feel they wouldnt have had

time for me I cant praise them enough to be honest Hertfordshire: Demographics Predicted Population Growth Integration in Hertfordshire One of the largest and most ambitious Better Care Fund programmes in the country

- 240m pooled budget Excellent relationships among partners High levels of aspiration and trust built on early success of HomeFirst Other integrated services also in operation: Integrated Access Early Stroke

Discharge Community Navigators What is it? new model of community care delivering a fully integrated service combining health and social care which will provide the right treatment at the right time in the right place Background Lower Lea Valley November 2012 74,900 population

Urban locality outskirts of London Small geographical area North Herts - July 2014 127,100 population Rural locality in north of county Very large geographical area HomeFirst North Herts (8am - 8pm, 7 days / week) Virtual Ward

Rapid Response Case Management 200 beds flex resource dependant on demand Supportive Discharge 10 dedicated beds

Professionals District nurses Physiotherapists Occupational therapists Mental health nurses

Social workers Dedicated homecare workers Admin Activity Lower Lea Valley North Herts Rapid response 25-30

55-65 Case management 40-60 60-80 Supported discharge N/A 30-40

Outcomes Lower Lea Valley North Herts Rapid response within 60 minutes 96.2% 96.1%

Case Management ALOS 50 days 41 days Supportive discharge ALOS N/A 7.2 days

HomeFirst GP Survey December 2014 January 2015 97% were extremely likely or likely to recommend the service to family or friends 95% agreed or strongly agreed that HF provided high quality patient centred care

96% agreed or strongly agreed that HF supported patients to self manage their conditions more effectively. HomeFirst GP Survey December 2014 January 2015 99% agreed or strongly agreed that HF has

improved the availability of community services in this area. 94% agreed or strongly agreed that HF has promoted joint working between HCT, social care and primary care. 96% agreed or strongly agreed that they are clear what HF does and how to refer to it.

The HomeFirst service has reduced my workload 73% of GPs agreed or strongly agreed 7% of GPs disagreed or strongly disagreed The most important views https://vimeo.com/107233652 Patient and carer feedback In my experience the service was first class

I was extremely impressed with this service everyone was kind and considerate & put me at ease, which in turn helped me regain my confidence All the Home First team were so caring and understanding without these lovely ladies I could not have managed. I thank you from the bottom of my heart each and every one of them Key lessons 1. GP leadership and engagement key 2. Strong leadership across partners 3. Invest upfront in induction and training 4. Need 5 months min adverts to go-live

Key areas for improvement 1. Multiple patient IT systems 2. Single management and governance 3. Culture eg, around risk tolerance 4. Embedding self-management What next?

Roll out to remaining 4 localities Care homes Telecare Clinical Pharmacist Isobel Hospice Health psychologists for self-management Interface geriatricians

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