Chiltern CCG plans integrated care to cut social care use

July board papers say that establishing a model of “seamless care”, with a greater emphasis on self care and prevention can also cut acute hospital admissions by 15 per cent.

The papers say: “At the present time, we are not proposing to discuss what the organisational changes might be to offer integrated care, rather the experience we seek to offer patients and carers – form will follow function.”

In Buckinghamshire one in six people are over 65, and this is set to rise to one in five by 2025, spelling a rise in people with two or more long term conditions.

The CCG has identified five main groups of people for whom integrated care is important: the frail elderly; those with more than one long term condition; adults with enduring mental health problems; those at the end of life; and children with complex needs.

The Chiltern take on integrated care would include drawing up a personalised care plan agreed with the patient and putting in place a single “trusted point of liaison”.

The latter would be a person who can work across organisational boundaries, act as an advocate, and support the patient to co-ordinate their own care and to promote a preventative approach.

The board papers say:

“We plan to co-design future models with patients and their carers to offer:

• Full support for self-care which includes excellent patient and carer information, supported by education sessions and expert patient programmes, support groups and online networks, shared decision making and increased use of technology;
• Prescription of lifestyle changes as part of treatment, and social prescribing that requires changes in behaviour, knowledge and confidence of front line staff to raise lifestyle issues along with directories of community assets and additional support services to refer people to;
• Addressing mental wellbeing needs for patients and their carers including advice on staying healthy and being emotionally resilient;
• A tailored approach for higher risk groups which include age, social class, black and ethnic minorities, and men; and
• Optimised management of long term conditions including care planning, patient defined outcomes, detection of co-morbidities, proactive case management, rapid access and of course, health and social care co-ordination.”