The emerging model of care shows how we, as an alliance of five local providers, aspire to be different and how we would like to shift the control back to people, enabling them to stay healthy and independent.

 

Key features of the model of care are outlined below:

  • Person focus: The person is at the centre of the model with services tailored to meet their needs. The services are wrapped around the person to ensure that they receive the right care, at the right place and at the right time. Funding for services will be based upon delivering patient-focused outcomes.
  • Holistic, personalised approach: We understand the strong interdependencies between community, social and health factors.  The model of care looks at the person in totality – health, psychological and social factors. 
  • Multidisciplinary team aligned to 6 GP networks: The model will be delivered using existing GP networks enabling GPs and a range of health, social care and voluntary sector workers to work more closely together.  The team will reassess individual care plans, address any gaps in a collaborative way and make more effective use of the local team and services. 
  • Focus on staying healthy and independent: The model focuses on preventing ill health, enabling people to keep themselves well and independent for as long as possible.  Community networks and third sector will play a bigger role in promoting independence and self-care; they will play a key part in meeting residents’ community needs, providing education and long-term management sessions.
  • Self-care, self-management and shared decision making: Frontline workers will work in partnership with the person, advising on, respecting and supporting their individual choices
  • One trusted assessment, one care plan (my life plan) shared across all agencies (shared care record): The person will be instrumental in developing their life plan.  Access will be available to health and care professionals to enable continuity of care and support between different organisations. 
  • One person to speak to: The person will only need to tell their story once; they will have access to one professional (care coordinator/system navigator) who will provide continuous support throughout their care. 
  • Building an efficient system overall: There will be greater financial sustainability  across the health and social care systems.  What might once have been spent on hospital care will now be spent on supporting the person at home in their community.