Local people with the greatest health need are being supported by three new integrated locality teams in Charnwood, North West Leicestershire and Hinckley and Bosworth.
Working jointly with local GP practices, the teams are jointly led by community nurses as well as colleagues from social care, GP federations and the councils in our three localities.
Together, they have initially identified three specific groups of vulnerable patients who could most benefit from the new proactive approach. These are:
• Adults with five or more chronic conditions
• People who are frail - regardless of age
• Adults who are likely to require higher than average hospital care over the next year
The new teams will make it easier for GPs, community matrons, district nurses and social care colleagues to work more closely together to deliver more joined up care for patients, as they integrate into one place based team.
They will be able to better coordinate and plan patients’ care to help patients to have better control of any long term conditions and reduce the need for them to attend multiple appointments with different teams, having to repeat their story or assessments each time.
Patients will be able to attend appointments and receive their care at home or in their local GP practice or clinic as much as possible. As required, the teams will also have improved access to specialist support such as community psychiatric services and palliative care services as well as to hospital-based teams.
Dr James Ogle said: “Over the last year, we have worked closely with patients and staff to look at how we can better care for our patients who have more complex health needs. We have also learned from similar projects around the country. We have worked with our local teams to review how we work, the assessments we provide, the governance processes we need and the roles and systems we need to put in place.
“The new integrated locality teams will provide a more consistent, proactive service to patients. The range of experts in the teams will work together to help patients to have more control over their condition and to self-manage where possible; helping them to stay as healthy and independent as they can, for as long as possible.
“If a hospital stay is required, patients will be supported to return home quickly and safely with the right support in place without the need to contact several different organisations.”
This is part of the Better Care Together programme and similar teams are also being developed in East Leicestershire and Rutland CCG and Leicester City CCG.
To hear more about the West Leicestershire CCG teams (in particular Hinckley and Bosworth), you can register to attend their exhibition, AGM and conference on 11 September from 5pm. Visit www.westleicestershireccg.nhs.uk/agm2017 to register and see the programme.