Delivering Integration Together
The development of integrated care will aim to ensure services are delivered together, linking in a range of care services to provide local people with a better experience. The development of an integrated care system for those people who are aged over 65 with one or more long-term conditions will focus on:
- Early intervention
- Maximising independence through the delivery of the right service at the right time
- Optimising patient choice and control
The long term vision of local health and care services is that through an integrated strategy, within five years, patients will see a transformed health and care system where there is:
- Early detection of long term conditions
- Support to ensure that patients are empowered to manage their own condition/s
- A proactive approach to identify people at risk of needing an increased level of care to ensure appropriate support is in place before a crisis situation occurs
- The right care delivered at the right time through primary care, community services and the third sector working together in ‘Dedicated Core Care Teams’
- Coordinated Care through services being delivered by multi-disciplinary teams holding regular case conferences and from having co-located teams
- Personalised care planning with access to appropriate specialist support in the community
- Supported hospital discharge to ensure that patients are only in hospital when they require an acute episode of care
The Integrated Care Programme team have developed links with community groups to further improve our health and social care services and improve the outcomes for our patients.
The creation of the Hililngdon4All forum means there is a now a central point where community groups can engage with a range of health and care partners.