Dorothy Edwards Assistant Director Primary Care & Partnerships

Transcription

1 Dorothy Edwards Assistant Director Primary Care & Partnerships

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3 11 networks in place since 2009 Grouping of health, social care and third sector partners Focussed on the needs of small geographical populations Taken a multi-disciplinary, bottom up approach to specific project areas based on local need

4 Understand and meeting local need tailoring services Platform for delivering and organising out-of-hospital care Improving health outcomes Improving patient experience and delivering person centred care Managing complex patients with co-morbidities Help create new workforce models

5 Pathways with secondary care Shaping service integration Improving Population Health Community Networks Managing Community Health Services Developing Primary Care Services Networks becoming operational management units by April 2015

6 Integrating Health and Social Care Carmel Donovan Working across the interface with secondary care Dr Andy Muir Working with the third sector Dr Richard Tristham Opportunities for primary care Dr Jane Harrison

7 Integrating Health and Social Care Programme Older and Disabled People Services May 2011 October 2013 Whole System Transformation Carmel Donovan 1st November 2013

8 Vision Statement to deliver the best possible local health and social care to people living in Bridgend in order to enable them to live as independently as possible and to ensure that they are protected from harm.

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10 Bridgend Community Services Access Points April 2011 The Public Families and Carers Professionals BCBC Customer Care Centre LA Enquiries Housing & DFGs Blue Badges Council Tax & Housing Benefit Third Sector Individual Organisation s access points Carers Centre BAVO District Nursing GPs Practice Nurses Social Services Hospital Community Equipment Hospital OT Community OT BridgeStart OT Reablement OT ERS OT Contact Assessment and Review Team Older People Social Work People Under 65 Social W Community OT Advice/ Info/Sign Posting to Other agencies CIIS Single Access Point ERS Telecare Reablement Occupational Therapy Hospital GP CIIS Community OT Primary Care GPs Hospital Referrals Social Services Therapy Services Mental Health Learning Disability Dementia MHOP Single Access Point MH Services Single Access Point LD Services Single Access Point Dementia and MHOP Mental Health Services Learning Disability Services Anything Else? BCBC Heath Board Third Sector Integrated Services

11 Bridgend Community Services April 2013 The Public Families and Carers Professionals Mental Health Social Work Including Dementia Learning Disability Social Work Integrated Referral Management Other ABM UHB Secondary Based Specialist Services Mental Health Learning Disability Dementia MHOP Third Sector Brokerage Community Resource Team Services Community Network Team North Community Network Team East Community Network Team West Long Term Care Planning and Comissioning Single Access Point MH Services Gate way to third sector advice and support Nursing Led Early & Mobile Response Services Therapy Led Re-enabling Services District Nursing Social Work District Nursing Social Work District Nursing Social Work CHC Joint Packages QA & Contract Monitoring Locality Planning & Services Single Access Point LD Services Single Access Point Dementia and MHOP Social Work Led Complex Care Community Occupational Therapy Community Occupational Therapy Community Occupational Therapy FNC ASC Planning Sensory & Rehabilitation Services Network Board Network Board Network Board Residential Support at Home and Short Break Serrvices Community Services Commissioning Integrated Community Equipment BCBC Heath Board Third Sector Integrated Services

12 Dr Andy Muir Clinical Director Primary Care NPT Locality

13 Diabetes Out Reach Clinics in Primary Care Improved knowledge, confidence and ability in PC to prevent referrals to Secondary care. Respiratory Advice Line Supporting clinical decision making in PC and prevention of referrals to secondary care. Integrated Community Services Integrated Health, Social Care and Third Sector Services supporting frail older people.

14 Improving Primary / Secondary Care Interface and access to specialist advice. Increasing Integration between Health, Social Care and Third Sector. Developing range and level of services outside of the hospital. Managing demand more appropriately across the system, responding to need and increasing quality for the service user.

15 CNs as Operational Units of Management in NPT will enable: Effective local engagement with directorates, partner organisations, primary care and communities. Identification of need using localised information. Improved local management and ownership of resources for community services and primary care matched with need and demand. Interfaced with Unscheduled Care realigning and developing services in the community. Health and social care workforce integration resulting in single point of access, less duplication of resources and effort resulting in increased capacity.

16 What could we be doing at Community Network level? Priorities and challenges from a Third Sector Perspective Amy Meredith Health, Social Care and Well Being Facilitator Swansea Council for Voluntary Service (SCVS)

17 Dr Richard Tristham Clinical Director for Primary Care Swansea Locality

18 What have we done to date?

19 We are a useful resource, which unfortunately many health professionals are unaware of It was heartening to see the interest on the faces of those present when we talked about what we do in the locality. This was an ideal opportunity to address a large group of professions to promote services provided by our organisation. Lot of enquiries on our services, lots of information given out, lots of questions asked and information given.

20 We received 40 requests from patients for additional support and information to help manage their condition. As a neurological alliance we are able provide information on a range of neurological conditions and signpost individuals to appropriate support for their condition. We have now provided all 40 patients with information, advice and details of local support groups that they can access. We have to date, provided appointments for 5 people for welfare benefit advice, 4 people accessed holistic therapy services in February and 4 other contacts were made in terms of follow up advice. A young man with depression and anxiety is now getting weekly support from a project volunteer - a fantastic result from my attendance at the practice.

21 We were able to spend time with the respiratory nurse, to highlight the services we offer and provide leaflets and information about the support group. The respiratory nurse has also agreed to promote the group to patients and include our details in the newsletter that is sent out to 300 COPD patients. 1 Mental Health Voluntary Organisation spoke to one of the Primary Care Mental Health Liaison Nurses at a GP Practice and has subsequently received 5 referrals to the project from the Primary Care Mental Health Liaison Nurse since. As a result of being at the Practice I have two Health Visitors making referrals to our early year s project.

22 As an organisation we really appreciate the opportunity to make people aware of our services. Particularly within a surgery, as service users may have recently been diagnosed with an illness that requires the support of adaptations, repairs etc to ensure they remain independent in their own homes. It s useful to have presence in GP surgeries and be promoting the third sector working alongside health. As a result of this pilot one of the Practices signed up as a member of the City of Sanctuary and has agreed to display our welcome stickers, hold information about volunteering and social support groups as well as signpost refugee and asylum seeking patients to specialist counselling services.

23 Both staff and patients found the pilot extremely worthwhile. By tailoring the times/dates of stands with specialist clinics that were running, this allowed us to capture those patients that would ideally benefit from help/support. An excellent project that I really hope will continue to run. In general, the display stands highlighted the individual organisations well and supporting materials were freely available, making the experience simple but constructive. The overall experience I believe adds value to participating practices for both patients and staff.

24 Continued emphasis on awareness raising ESF Funded Healthy Partnerships Project Protected Learning Time Sessions Team Meetings

25 Partnership Working Service Delivery Information Sharing Quality Assurance

26 Citizen Engagement Community Voice Programme Development of Patient and Carer Participation Groups in Swansea linked to the community network areas.

27 Sound foundations in place Networks should have a role at the centre of redesigning care, and directly influencing the pattern of services Discussion phase until mid December please share your views Significant programme of change from January to April 2015