Out of Hospital Care (incl. Care Homes and Quality in Primary Care)

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Hartlepool & Stockton-on-Tees Clinical Commissioning Group – “Operational Plan on a Page” Vision Strategic Aims Workstreams Outcome Domains Outcome Ambitions To develop outstanding, innovative and equitable health and social care services, ensuring excellence and value in delivery of person centred care working across both Health and Social Care • Health and Well-being • To develop integrated initiatives with partners to encourage people to make healthy lifestyle choices, improve quality of life and manage the longer term needs of the community • To improve the quality of education and support offered to patients with long-term conditions so that they feel confident in managing their own condition and avoid admission • To deliver integrated support to mothers in order to promote a healthy pregnancy and the best start for babies and children and manage the longer term health needs of the community • To develop integrated services to improve health awareness in order to improve screening, encourage earlier diagnosis and avoid emergency admission including primary prevention interventions i.e. smoking, alcohol • To ensure sufficient capacity commissioned to meet the demand following the development of integrated services • Implementation of a new pathway of care for people with COPD to ensure equity across both localities Bringing care closer to home Tackling health inequalities • Out of Hospital Care (incl. Care Homes and Quality in Primary Care) • To maximise independence and quality of life and help people stay healthy and well through the development of integrated community health and social care services with the focus on long-term conditions, frail elderly and dementia. • To support and develop Primary Care in order to increase capacity and reduce demand on urgent care services • To continue to support primary care in reducing variation in practice in order to improve health outcomes and deliver quality, innovation, productivity and prevention (QIPP) • To support personalisation and choice by developing range of coordinated alternatives to hospital and residential care services through investment in personal health and care budgets. • To improves access to community health and social care services 7 days a week in order to empower people with long term conditions to live independently Caring for an aging population Priority health conditions • Acute In-Hospital Care (incl. Urgent Care) • To improve outcomes for service users and carers through clearer and simpler pathways of care • To ensure the longer term management of patients remains within the oversight of the registered practice • To streamline care and reduce activities that are being carried out by the same or multiple organisations ensuring services are available in the right place to support individuals in the management of their condition • To improve access to a range of community health and social care services 7 days a week to ensure the provision of responsive services in and out of hours in order to reduce the demand on urgent care provision • To commission a clinical support service for NEAS paramedics to reduce the need for hospital admission where this is avoidable when appropriate • To continue to improve commissioned services in collaboration with the Provider to ensure key deliverables are implemented through inclusion of requirements as contract developments Securing additional years of life for the people of England with treatable mental and physical health conditions Improving the health related quality of life for people with long term conditions, including mental health conditions Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital Increasing the proportion of older people living independently at home following discharge from hospital Parity of Esteem Improving health and preventing ill health in partnership Reducing inequalities Increasing the number of people having a positive experience of hospital care Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions. Helping people recover from episodes of ill health or following injury Ensuring that people have positive experience of care Treating and caring for people in a safe Environment and protecting them from avoidable harm Improving quality in primary care • Mental Health, Learning Disabilities and Dementia (incl. Winterbourne) • To continue to enhance and improve the health and well-being for patients with dementia and their carers through the production of an integrated mental health strategy • To review current mental health pathway for perinatal care to improve patient experience and access. • To Improve the mental health well-being of people who have mainly mild to moderate mental health problems and other unmet health and social care needs through improving access to community based services. • Improve outcomes for disabled children and children with complex health needs and streamline services to optimise integration through review and redesign of existing services • Continuation of the Tees CAMHS transformation and pathway improvement to ensure that primary mental health services meet the needs of children and young people with early stage mental health difficulties • To work with Local Authority partners to deliver an integrated Advocacy Hub to respond to the challenges and meet the quality requirements of the Winterbourne Review, improving access to advocacy support within residential units Quality and Safety Improving the patient experiencer • Medicines Optimisation • To ensure the best possible outcomes for patients who are supplied medicines and support the development and education of pathways i.e improved management of COPD in Primary Care • To ensure that the most appropriate choice of clinically and cost effective medicines (informed by the best available evidence base) are made that can best meet the needs of the patient. • To ensure that Medicines optimisation becomes part of routine practice across commissioned services • To ensure medicines use is as safe as possible by providing stewardship in line with national guidance • To support primary care in the deployment of the electronic prescribing service (EPS) Seeking best value for money in budget