Whole systems integrated care
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Whole Systems Integrated Care. Central London / Westminster. Whole Systems Event – Capture of discussions. 9 nd April 2014. Who attended. *No representation from the Imperial or Chelsea and Westminster Hospital.

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Whole Systems Integrated Care

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Whole Systems Integrated Care

Central London / Westminster

Whole Systems Event – Capture of discussions

9nd April 2014


Who attended

*No representation from the Imperial or Chelsea and Westminster Hospital


Participants were asked to think about the following three questions after watching ‘Sam's Story’

  • Social isolation

  • Access to information

  • People falling through the net

  • Communication between the hospital and the GP

  • Lack of support when patients return home from hospital

  • Inter service boundaries

  • No coordination

  • Lack of good out of hours care

  • Financing of home care

  • Services are not rapid and responsive to me as a patient

  • Lack of dignity and respect for patients as individuals

  • Confidentiality – where sharing would support patients it should be made possible

  • Patients do not have enough control of their own destiny

  • Do not know / understand what services are out there and how to access them, especially within the voluntary sector

  • The lack of one team responsible and accountable for delivering my care plan

  • Many services the GP holds the ring on who is referred

  • Lack of support for carers

  • Turnover of staff

  • Lack of honestly and openness

  • Services / people need to do what they say they will do, when they say they will do it

  • Old attitudes, territory protection

  • To understand how the system works

  • A longer appointment with GP to discuss my complex health needs

  • Access to specialist professionals who understand my condition

  • I want to be able to plan my care

  • I want one person coordinating my care who understands my needs and can connect me with the right people

  • When I go into hospital I want to go home and do not want to go back into hospital unless my condition

  • I want to understand what peoples roles are and what support is available to me

  • I want staff to be consistent and give me the same advice regardless of who it is I am talking too

  • I want to know what free services can help me

  • I do not want my hospital appointments or operations to be cancelled as this makes me anxious

  • I want access to interpreter’s

  • I want to be able to view my record / care plan

  • I want a care plan that everybody follows

  • I want to be involved in planning and options about the care that I receive

  • I want to access services at a time that is convenient to me

  • I want my care to be right for me, not people who are like me

  • I want less bureaucracy, and less forms to fill in, I just want help with my care

  • I want professionals to explain to me what is happening

  • Acknowledge the role and expertise of carers, and their ability to make decisions

  • Trust patients and carers to know what they need and the best way to get it

  • Prevent peoples health from detraining

  • Ensure all patients with complex needs have a care plan

  • Increase confidence in information sharing arrangements

  • Being able to talk to somebody when patients feel they need too

  • Services that are personalised to ME

  • Personal decision making on what services are accessed and when they are accessed

  • Everybody should be able to plan their care regardless of funding and eligibility

  • I want one number that I can ring when I need help

  • End weekend delays, information readily available all the time

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  • What stops people from achieving these goals today?

  • Sam’s goal was to be able to live independently at home…what goals do you have for your wellbeing?

  • What common goals should Central London CCG / Westminster support everybody to achieve?

http://www.kingsfund.org.uk/audio-video/joined-care-sams-story


Home based and residential

What could Whole Systems Integrated Care look like in Central London?

Detail based on discussions at CLCCG’s Whole Systems Event on 8th April 2014

  • Text

  • Hospital

Hospital

  • GP to remain responsible even when the patient is in hospital

  • Responsibility for admitted patients to coordinate discharge

  • Care plan constantly reviewed with detailing goals and wishes

  • Discharge planning with people from access the system, to include carers, family, care coordinator

Home based and residential care

  • 24 hour care

  • Care plan constantly reviewed with detailing goals and wishes

  • Respite care

  • Domiciliary care

  • Pharmacist input

  • Formal appointment of family member to care (this to be recognised by the professionals)

  • Home care help and choices of time to access this home care

  • Supported living units

  • Text

  • Rapid response in the community

  • Routine care in the community

  • Text

  • Home based and residential care

Routine Care in the Community

  • Single assessment by a nurse or Doctor

  • GP coordinator

  • Team coordinator

  • Flexible team to support changing patient needs

  • 24 hour care

  • More services in the community

  • One computer system with a good backup

  • Clinical care coordinator

  • Foot care

  • Minor Surgery

  • Phlebotomy

  • Inter team referral for specialist opinion

  • Care plan constantly reviewed with detailing goals and wishes

  • Service support that is flexible based on needs and changing needs

  • Good access to GPs

  • Use of pharmacists in the community

  • Access to equipment such as wheelchairs, and handles

  • Single record across H&SC

  • Variety of times and appointments to suit different needs

  • GP to plan support in advance of patients going into hospital

  • Establish community wards for managing long term conditions and predictable hospital admissions

  • Structured care plan based on wishes of the patients – not based on what is on offer

  • Longer GP appointments

  • Flexible short term input when people with fluctuating needs require it

  • Local diagnostic units which stop patients having to go to hospital

  • Co-located multidisciplinary teams located in the community which include social care

  • Empowerment and self care

Rapid response in the community

  • Better access to OOH services

  • Care plan constantly reviewed with detailing goals and wishes

  • Respite Care

  • Access to a rapid service that is an alternative to 999

  • Alert system for people involved in an individual persons care to alert to crisis or hospital admission

  • Access to GPs / nurses in a crisis situation

  • Integrated re-ablement and rehabilitation in the community

  • Rapid responsible available to all (mobile doctors)

Empowerment and self care

  • Befriending

  • Information advice in suitable formats

  • Housing services

  • Education for self-management

  • Signposting to voluntary sector services

  • Wider voluntary support network

  • Integrated care plan written by myself and my career constantly reviewed includes my personal goals and wishes

  • Drivers / volunteers to bring patients to services

  • Telehealth

  • Education on medicines

  • Some services geared around improving mental wellbeing

  • Advice on benefits and welfare

  • Advice on exercise and healthy living in one place

  • Personal budget for those who would benefit


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