Integrated care and support

It is important for proactive and jointly delivered care to be provided for the most vulnerable people and their carers, and this will be achieved through the establishment of integrated teams and joint processes that support admission avoidance and timely discharge from hospital. Customers will only need to tell their story once, knowing their needs will be met by staff who work together to achieve the best outcomes. This is being achieved by continuing to progress existing and new initiatives to:

  • Improve Delayed Transfers of Care and flow through the system – using the tools and systems recently developed to reduce length of stay.
  • Redesign health and care services using a population health management system in collaboration with the Out of Hospital programme.
  • Integrated Care Partnerships – Adult Social Care will continue to explore and implement integrated and aligned strategic commissioning and operational delivery of support to those people in need of care.
  • Dementia – Increase the reach of support to people newly diagnosed and those living with dementia through delivery of the dementia strategy.
  • Design and implement demand management solutions, including Discharge to Assess and Moving on Beds to reduce prolonged hospital length of stay and prevent delayed transfers of care. Additional Moving on Beds capacity will also continue to be funded.

Frailty and Falls Prevention>>

We have developed with our partners a comprehensive information pack and Frailty eLearning for staff working in the health or care sector.

This is designed to help you understand everything you need to know about frailty and how this contributes to falls and our local falls prevention offer in Warwickshire.

Just to act as a reminder, falling is a serious and frequent occurrence in people aged 65 and over. Each year 35% of over-65s experience one or more falls and the rate of admissions following a fall among Warwickshire residents is significantly above the national average. Due to Covid-19, more residents are staying inside their homes and not venturing out as they would have done before. This decline in activity risks older residents, aged 70 plus who are prone to falls and trips, being admitted to hospital. People who suffer a fall often also experience a loss of confidence which can result in social isolation and a reduced ability to lead an independent life.

Below are links to the information pack to give you a good insight into the risk factors attributed to falls for those who are frail, which escalates in severity of the type of care needed for someone with a risk level from low to moderate to high risk. The teaching modules are cut down into bitesize pieces, so they are easy to digest and to follow.

1. INFORMATION PACK – to learn about risk identification and the support available including how to refer to the local NHS Integrated Single Point of Access (iSPA) for customers/or patients you identify as moderate to high risk of falling;

2. Undertake the Frailty eLearning (See Page 8 within the Information Pack)

3. The Healthy Ageing website to access the advice, information and core strengthening exercises available to customers/or patients as part of our new self-care offer.

4. Marketing collateral (posters) – please feel free to share the following posters to the public or your staff.

  • Top Tips – Top Tips to stay happy, healthy and independent
  • Healthy Ageing – Promoting Healthy Ageing Website
  • Active at Home – Step by Step Follow Along Exercise Sheet


WCAVA’s Social Prescribing Project »

Warwickshire Community and Voluntary Action (WCAVA) and the Coventry and Rugby Clinical Commissioning Group (CRCCG) are working in partnership to deliver Social Prescribing in Rugby, known as ConnectWELL.

The ethos of the project is to improve people’s health and wellbeing. ConnectWELL signposts and supports individuals to access services and activities delivered by the voluntary and community sector and statutory partners to address underlying and causal factors.

Help to Live at Home »

Warwickshire County Council’s online resource of services available to help people to remain in their own home.

Mental Health and Well being >>

Warwickshire County Council ‘s online resource to support good mental well being.

Living Well with Dementia >>

Coventry and Warwickshire’s online resource of dementia support services.

NHS Choices – Your Health >>

NHS guide to long-term conditions and self care

Hospital to Home Service

Support for people over the age of 65 to return home following a visit to Accident and Emergency (A&E) in the South Warwickshire Foundation Trust Hospital and the George Eliot Hospital

Rethink – Mental Health Charity >>

Mental health charity that provides advice and support to empower anyone experiencing a mental health problem. And which campaigns to improve services, raise awareness and promote understanding.