Health and Care Interface

The challenge

Across the country, local health and social care systems do not work closely enough together. The best interests of patients are sometimes lost as service providers, healthcare specialists and social workers too often work in silos. This can mean that patients’ needs are not addressed early enough, their independence is not prioritised, and there is insufficient coordination between the services provided. Every day, this is resulting in avoidable hospital admissions, increased costs, pressure on social care services at the point of discharge, and poor patient outcomes.

Our solution

Addressing demand at the interface of health and care presents the biggest opportunity to deliver better outcomes for less. Our solutions enable clients to significantly improve outcomes for patients and social care users by better managing demand for services, and therefore also to reduce costs.

Interface Demand Model

Who is accessing both health and care services?

Often we find that there isn’t enough shared understanding about this group. Who are they? What services are they accessing – and how, when, at what cost and with what outcomes? The Interface Demand Model enables organisations to identify this cohort by mapping health and care data at an individual patient level. The model identifies the levers which could significantly affect both outcomes and spend.

Case Note Reviews and Behavioural Observations

What is happening to people accessing both health and care services?

Clinicians or social workers typically deal with an immediate presenting need, such as an urgent admission to hospital or a social care assessment. Case Note Reviews form a key part of iMPOWER’s reflective practice and makes it possible to analyse what has happened to individual patients over a period of time. It also identifies missed opportunities for alternative pathways. Behavioural observations also provide insight into how decisions are made on the frontline and show the impact that different types of conversation between professionals and patients can have.

Benefits mapping and metrics process

Is activity focused in the right places?

Through mapping the benefits of change, we can show the impact of transformation activities at the health and care interface, whether related to the Better Care Fund (BCF), improved Better Care Fund (iBCF) or another initiative. Identifying and understanding the group of people accessing health and care services and the benefits of change is only the first part of the journey.

We work in partnership with an inclusive ambition across health and care at many different levels:

• Intermediate care services which respond to individual needs, prevent hospital admission and support discharge
• Locality, community and place models which proactively support people to live independently in their own homes
• Personalised care including integrated care plans, personal health budgets and social prescribing

Personalised Care

The more engaged someone is with their own health and healthcare, the less treatment they need and the faster they recover from illness. Personalised care is an approach which recognises the benefits of taking increased responsibility for our own health and care. We work with clients to implement and design models related to:

• Integrated care planning
• Social prescribing
• Integrated personalised commissioning
• Personal health budgets