Well Connected Governance

Urgent CareIntegrated

Out of hospital care

Specialised Services

Future of Acute

Hospital Services

Future Lives

Tran

sfor

mati

on

prog

ram

mes

Worcestershire Health & Social Care Economy Leaders Forum

Worcestershire Acute Hospitals

TrustBoard

Health and Wellbeing Board

Worcestershire Health and Care Trust

Board

Worcestershire County

Council Cabinet

Wyre Forest Clinical

Commissioning Group

Governing Body

South Worcestershire

Clinical Commissioning

Group Governing

Body

Redditch and Bromsgrove

Clinical Commissioning

Group Governing Body

NHS England

Area Team

Aims -

• To develop and implement an integrated care assessment electronic record for all partners and patients to then use.

• To keep patients / service users at the heart of the project by working to the principles of Co-production. The electronic record will need to be mirrored on paper for some service users who are not ‘digitally included’.

Progress since September -

• We have an agreed ‘common data-set’, produced as a result of extensive engagement with service users, professionals, carers and volunteers.

• We have started work on the detailed IT solution, finalising the user requirements and scoping out the options for interoperability.

• We have started working on a benefits-led business case which really emphasises the benefits to patients / service users, not just the Well Connected organisations

iCompass – Integrated Care Assessment & Support Planning

Next Steps

• Ensure that work continues in accordance with Co-production principles.

• Refine the business case and quantify the identified benefits with £-signs

• Agree a timescale for a phased roll-out of the IT solution, identifying a cohort of service users to test iCompass and thoroughly evaluate it.

• Understand and accept that Version 1 probably won’t be perfect!

• Continue to engage with as many people as possible to raise awareness of iCompass and promote the benefits to the entire health & social care economy.

The Falls Pathway

• We are in the process of re-evaluating the pathway which was originally implemented in 2010. The current pathway has become a victim of its own success with approx 250 people being identified as ‘at risk’ each month. This has resulted in delays people being offering preventative interventions and referred for additional support.

• Others areas of the pathway have been identified as requiring improvement, although some elements continue to work very well.

• One key area of focus is the need to share information more effectively across parts of the health & social care system, so the project links closely to the iCompass work.

• The new pathway has been broadly agreed now and (subject to testing) will be re-commissioned from April 2016.

The Falls Pathway

• We need to retain the current focus on prevention and work to the ethos that falls are everyone’s business.

• The VCS will continue to play a key role in both identifying those at risk of falling and supporting those recovering from a fall.

• The Initial Falls Risk Screening tool will assist with this….