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 will be achieved by:
- System-wide end to end review of transfers of care across Warwickshire in order to understand the reasons for delays and implement a jointly agreed action plan.
- South Warwickshire Foundation Trust (SWFT) and Warwickshire County Council (WCC) are continuing to optimise capacity of our co-located Home First service (CERT, ICT and Reablement)
- A population health management system to support the integrated, responsive model of care and better understand the local population’s health needs.
- Fully integrated, place-based mental health and social care teams around clusters of GP practices. They will have access to shared records and a focus on prevention and proactive care.
- Increased use of assistive technology via the Integrated Community Equipment Support Service (ICESS).
- Implementation of the dementia strategy across multiple partners to increase the level of support given to people living with dementia.
Warwickshire Community and Voluntary Action (WCAVA) and the Coventry and Rugby Clinical Commissioning Group (CRCCG) are working in partnership to deliver a Social Prescribing Pilot Project 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.
Warwickshire County Council’s online resource of services available to help people to remain in their own home.
Warwickshire County Council ‘s online resource to support good mental well being.
Coventry and Warwickshire’s online resource of dementia support services.
NHS guide to long-term conditions and self care
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
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.
South Warwickshire Over 75’s Project »
South Warwickshire Clinical Commissioning Group are running 3 pilots for the Warwickshire Over 75’s population, below is a video explaining the pilots: