Integrated Service Delivery Across the Whole Patient Pathway Johan Holte Consultant Physiotherapist Sussex MSK Partnership

something truly outstanding

Drivers for change Sustainability

What the Commissioners are looking for Co-ordinated Care Approach Right person first time One-stop shop where possible Rapid diagnostics Referral to treatment times: 8 weeks Direct Listing SDM intrinsic to process Supported self care Rapid advice & guidance Fitness for surgery + discharge planning Shared Decision Making Education & training Rehab post-op Cost reductions IT solutions

Integration across multi-disciplinary teams Person-Centred self care Shift activity from secondary care into primary and community Outcomes that matter Shift from a medico / surgical model to a bio-psychosocial model

Safe Effective Timely Patient- centred Efficient Care that is respectful of and responsive to individual patient preferences, needs and values Patient values guide all clinical decisions No Decision about me without me What’s the matter becomes – “what matters to you?” Patient owned records Mass customisation – “Markets of One” Minimally disruptive medicine

Single Electronic Patient record, Service IT and Knowledge Hub Integrated MSK Service Primary Care Single Electronic Patient record, Service IT and Knowledge Hub Self Care In-patient care Presenting condition specific care pathways

Condition Specific Care Pathway Self care Personal Care Plan Primary Care In-patient care Integrated MSK Service

Early intervention RA GP MDS on referral Triage Triggers urgent appointment Community clinic for diagnosis and treat to target