Whole Systems Integrated Care Older Adults West London

Whole Systems Integrated Care (Older Adults) West London CCG Update for the K&C Health and Wellbeing Forum – 20 October 2015 1

What is Whole Systems? • Patients will be supported to develop care plans to support their health and wellbeing • There will be more time available to discuss a person’s needs with those who are supporting their care • We are launching hubs – one at St. Charles and one at Violet Melchett • The most vulnerable patients will be invited to attend the hub for a detailed care planning appointment and they will be able to access other services and professionals while they are there. For example: - Blood testing and diagnostic services such as x-rays - Pharmacy input - Social care input - Services such as continence, cardiology, diabetes etc • Transport is available if someone is not able to travel to the hub on their own • We are launching a self-care pilot to support people to keep themselves well 2

St Charles Integrated Care Centre launch St Charles Integrated Care Centre opened on 21 September 4 practices currently delivering sessions from the hub Social workers are on-site 5 days per week on a rotational basis Medicines management team have started working with one practice at the hub and plan to expand • Positive feedback received from staff and patients: Ø Patients have commented that they are happy that they have enough time to discuss their key concerns with their GP/Case Manager Ø It’s a quiet space away from the surgery for uninterrupted time Ø The hub has huge potential in terms of bringing together teams including social care and medicines management Ø Patients have had the opportunity to talk directly to the social worker while at the hub • • 3

Programme update South hub Self-care Workforce • Clinic schedule developed for Violet Melchett and discussions underway with services regarding co-location • Building works will be an 8 week programme once they commence • GP training is commencing in the south to prepare for go-live • Specification has been developed and signed off for delivery of a self-care pilot • Pilot is being prepared to launch and is being delivered by Kensington and Chelsea Social Council, in partnership with other third sector providers • Focus on goal-setting and self-care planning • We are in the process of advertising Case Manager and Health and Social Care Assistant posts. These will go out to national advert in the near future via NHS Jobs and the Guardian online • Training programme being developed for new workforce. Aspiration is that all staff working in the model will have a mix of health, social care and self-care knowledge Outcomes and evaluation • KPIs will be grouped into 5 domains: quality of life; safe and effective care; professionals working in integrated environments; financially sustainable care; efficient care delivery • Task and Finish Group is developing key measures related to patient experience and proactive preventation 4