An Integrated Public Health / Housing Systems

1. Contribution to QIPP programme

1.1. Cost/Savings

1.2. Innovation

1.3. Productivity

2. Home from hospital: a partnership approach

3. Work with Housing Associations

3.1. Influence on health outcomes

3.2. Work in most deprived areas - people most likely to present at a later stage of their illness - and increased chance of readmissions

3.2.1. Higher Mortality

3.3. £315 Million saved form investments in health and social care budgets

3.4. Offer preventative services

4. An integrated health and social care IT system - Although not new -See the Torbay Trust - HSJ article

4.1. Barriers - Linking the datsets

4.1.1. The divide between primary and secondary care in the NHS, and also that between health and social care.

4.1.2. NHS management culture often talks about innovation yet demonstrates a fundamentally 'permission-based' and ‘risk averse’ approach

4.1.3. The absence of a robust shared electronic patient record

4.1.4. Policy barriers to integrated care

4.1.5. Are Social Services and Housing integrated (I think no) - See article

4.2. Data Sources - See notes

4.3. Shining a light on the lack of current capacity and capability in community services to deliver care co-ordination and more intensive care in the home environment.

4.4. Innovative approaches are needed to sharing data together with a commitment to developing shared clinical records.

5. Facilitating Hospitals Discharge

6. Providing independent living - Improved Psychology welfare

7. Integrated Care Pathways

8. Avoid hospital admissions related to poor housing

8.1. Asthma

8.2. Stroke

8.3. COPD

8.4. CHD

8.5. Mental Health

8.5.1. HonOS Pbr system - contribution of housing

8.6. Admissions associated with old-age

9. Reduce emergency admissions and GP referrels

9.1. More efficient referral pathways - Treatment at home

10. Maximise technology like telecare: Patients of the future

10.1. COPD / Diabetes

10.2. Blood pressure and cholesterol levels

10.3. New digital technologies to help vulnerable people, such as the elderly and dementia patients at home

10.4. Comprehensive monitoring technology coupled with telephone support is allowing the local authority and NHS to benefit through a reduction in costly ambulance call-outs and hospital admissions

11. Help older people to recover their independence after illness, stroke, injury or trauma

12. Social Workers unaware of clients medical needs -

13. Reduce number of bed days / avoid bed costly bed blocking - when support from social care or district nursing is not available in the community for vulnerable patients.

13.1. The NHS and social care must work together to ensure people have the support they need on leaving hospital

13.2. COST NHS £18.5 MILLION LAST MONTH

13.3. Lack of communication between acute and community services

14. Excess winter deaths - Highest in Europe

14.1. Fuel Poverty

14.2. Healthy Life Expectancy and Preventable Mortality

15. Need for information regarding the interactions between social care, housing and health

15.1. Improved analytical evidence to improve delivery of social care