Integrated Care takes a joined-up approach to health and wellbeing. We work together with local hospitals, community services, social care, GPs and mental health services to deliver care that considers all of the needs of a person, their family and their carers. By working together in this way, Integrated Care aims to reduce unscheduled hospital admissions, reduce the amount of time people spend in hospital and help people to manage their own health and wellbeing.
There are seven different areas we are working on.
In urgent care, we aim to make sure you get the right care, at the right time, in the right place – this may be in hospital, in your own home or in the community. We think you should only go to hospital when it is only really necessary and that you should get the right support when you leave. We have convened an Urgent Care Network to ensure our local system is working together to meet the rising patient demand for health services. A key part of our urgent care strategy is the introduction of the new NHS 111 medical helpline service to support patients who require urgent care.
Our neighbourhood team development aims to make patient-centered care a reality through working together with community, social, health, voluntary and hospital services in six geographical areas across west Suffolk.
We also have a programme to empower patients to make shared decisions with their health or care provider through building a self-management strategy and through training our health providers. To support this work the CCG has introduced ‘Health Coaching’ for GPs, which will support the development of Shared Decision Making skills in our practice members.
One third of people aged over 65 and almost half of people aged over 80 will have a fall. Through our falls and fragility fractures work, we aim to prevent this by assessing anyone at risk of having a fall. We are also working towards preventing people having a second fall by providing a specialist follow-up service.
There are over 25,000 family carers in West Suffolk. Many family carers have poor health because they spend so much time looking after another family member. We are developing a family carers’ strategy with our partners to make sure we look after the health & well-being of this group.
Stroke is another important issue in West Suffolk. In stroke improvement, we are considering the findings from the National Stroke Strategy to inform and implement a new model of care.
Finally, we have a number of projects relating to dementia. Through these, we aim to increase awareness about dementia in our health providers. We also aim to increase support for people with dementia by supporting them at home or in the community, and reducing the need for them to go into hospital where we can.
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