Wandworth Local Health and Care Plan - October 2019

55 Age Well - Health & Social Care Integration - what we will do Summary Description of the programme What will be different about our approach To integrate (join up) health and social care services to provide a better service to residents We currently have strong joint working across health and social care, including developing joint strategies and jointly commissioned services. We need to focus on the next stages of integration around the individuals’ experience of care What will we do Description of initiative What will be the impact How will we measure success Integrated intermediate care/reablement services Integration of intermediate care and reablement pathways and services with a focus on: a) rapid response to avoid admissions to hospital b) home first principles to support more people to receive services in their own home • Improved access into intermediate care services, and better coordination of services • Increased resource and activity provided closer to home, reduction of unnecessary admissions in hospital and shorter length of stay • Integrated services available in the community on a rapid response basis, with a re-provision of intermediate care beds to home based rehabilitation • NEL Admissions • % people accessing reablement on discharge from hospital • LOS • “91 day” reablement target • Improved patient experience Coordinated/ Integrated Complex Case Management • To build on integration of community services for people with the most complex health and social care needs • This includes review of Enhanced Care Pathway specification and social care team in Community Adult Health Services • More timely, coordinated access to health and social care services • Person centred and holistic assessments and interventions for individuals and their carers • NEL admissions • Joint care plans (is this an area for development 20-21) • More patients enabled to access the MDT meetings throughout the year. Falls Prevention Enhanced community exercise programme with access to evidenced based training • Better access to evidenced based falls services available in local areas • Specialist teams to provide training to a wider range of health and social care staff as preventing falls is everyone’s business • A better integrated service across health and social care to assess those who are very frail • NEL admissions • A and E attendances • Outpatient appointments • Improved patient satisfaction Enhanced Support to Care Homes More integrated health and social care for very frail, including residents in care homes Better access to care at home following a fall and access to falls prevention training and strategies to reduce the number of falls in the future • Better care provided in care homes as better and quicker access to NHS care • Improved training provided on an ongoing basis to care home staff • Better communication between GPs, the hospitals and the care homes through the use of the Red bag and better proactive care planning • Regular MDT meetings to develop strong care planning in care homes led by the GPs and supported by a wider MDT team • Greater collaboration with the LA regarding quality improvements in homes • NEL admissions • LOS in hospital • A and E attendances • Number of conveyances Integrated Equipment To build on integrated equipment offer, ensuring that the right equipment is provided at the right time (using trusted assessments across health and care as appropriate) • More timely provision of services • Reduce duplication/transfers between health and social care organisations • More efficient provision of equipment services • Recycling rates • Reduction in high delivery costs (improve equipment stores)