Model of Care for 65 and over Dr. Richard Hooker Clinical Lead West London CCG Integrated Care Team Paula Morrell Health & Social Care Assistant (HSCA) My Care My Way
My Care My Way Service • More Coordination – Case Finding, Care Planning and Holistic Case Management • More time – extended time with the GP • More Support – Case Manager (CM) & Health and Social Care Assistants (HSCA) • More Help – dedicated Integrated Care Centres (ICCs) • More Choice – access to self care services to support emotional and physical needs
Social prescribing • Refer people to a range of local, non-clinical services • Address people’s needs in a holistic way • A range of Arts (as well as social groups, learning activities, gardening, befriending, healthy eating, advice and a range of appropriate sports) 162
Social Prescribing - MCMW • Kensington and Chelsea Social Council (KCSC) manages the self care menu of services • Positively contribute to patients’ confidence and motivation • Long-term reduction in use of primary, secondary, and some tertiary care services
MCMC Quick Guide | Section X | Page 01
Self-Care Services on offer to MCMW There are currently 8 providers offering 15 self-care services 165
Self-Care Services on offer to MCMW Service Provider Link Up Open Age Information & Advice Age UK, Citizens Advice Westminster 1 to 1 Massage Life in Balance, ADKC Dementia 1:1 MSH Wellbeing, Age UK Exercise at home MSH Wellbeing, Age UK Walking support MSH Wellbeing, Age UK De-cluttering MSH Wellbeing, Age UK Escorting MSH Wellbeing, Age UK Safe at home Age UK Kensington and Chelsea Befriending Carers Trust Thames Creative befriending Resonate Arts Carers respite Carers Trust Thames Men’s only (group) Open Age Arts in the community (group) Resonate Arts Unwind drop in (Drop in massage) Life in Balance 166
MCMW Referral Process for Self Care 167
Evaluation Social Return on Investment (SROI) report July 2018 https://www.kcsc.org.uk/publication/social-return-investment-sroi-report
Primary Care Networks (PCNs) & Integrated Care Systems (ICSs) “By 2021, Integrated Care Systems will cover the whole country. Primary Care Networks will be a fundamental building block of every Integrated Care System, essential to achieving Integrated Care System goals” Investment and evolution: A five-year framework for GP contract reform to implement the NHS Long Term Plan - January 2019 BMA NHSE
Primary Care Networks (PCNs) & Integrated Care Systems (ICSs) “A primary care network consists of groups of general practices working together with a range of local providers, including across primary care , community services, social care and the voluntary sector, to offer more personalised, coordinated health and social care to their local populations” NHSE
Primary Care Networks (PCNs) & Integrated Care Systems (ICSs) • WLCCG - 250,000 people • 5 PCNs • 50,000 patients • 6,000 - 65y+ • 7%+ dementia prevalence • 420 living with dementia
Case Study
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