System Transformation Plan Building a Sustainable Future Better Together System Transformation Plan Building a Sustainable Future

Introduction Staff Workshops April 2012 Direction of Travel agreed and supported by Commissioners Pilots/Trials Professional leadership Consultation Next steps

Disease Management (20%) A Tiered Model to Prevention Level 3: Case Management (5%) Home Improvement, Supported Housing, Home Support, Telecare, Aids and Adaptations, Healthy Diet, Social Support, Crime reduction, Benefits Advice, Carer Support, Exercise Care/Case Management, Disease Management, Falls Prevention, Medicines Management, Expert Patient Programmes, Intermediate care, palliative care Level 2: Disease Management (20%) Level 1: Self Management (75%)

Risk Stratification Lasted until October Regional solution has been withdrawn Different CCG solutions Good case studies of case management in localities – need to publish success more Professional judgement – one size doesn’t fit all Data governance, Capacity

Single Assessment Multiple Forms Professional judgement Professional leadership Relevant to practice / frontline trials Record keeping Simplified forms Number Size

Working Model

Remote Working Trials Computers Pens Social Care had greatest benefit Health clinical system Training Cultural issues of real time recording with PC Now handed over to IT

Next Issues Assistive Technology Workforce planning Refining standard operating model Productive series – wards, communities … Patient led systems Frontline led innovation shared across Trust

Conclusion Local solutions will be different Advantage in sharing innovation Transformation topics led by teams not centrally Skill set not service