Care Managers Network June 2019 Jenny Turner Integrated Care Model Care Managers Network June 2019 Jenny Turner

Priorities – Integrated Care Model Staying well Self Care High Impact Users Social Care for Under 65 years Social Prescribing Reducing urgent admissions and attendance Falls and Frailty One Team Enhanced Health in Care Homes Framework Efficient discharge Discharge Co-ordination Transforming Care at Home

Social Care for Under 65 years Staying Well Self Care People are self reliant and able to manage their long term condition PAM and HOPE Health Navigators and Coaching High Impact Users Proactive targeting of those who use services the most Plus size scheme SPACE Independence scheme Reduce placements and care packages Social Care for Under 65 years Training and Education Making Every Contact Count Social Prescribing People can access community assets Wellbeing Co-ordinators Shared Decision Making Falls and Frailty Early Identification and Prevention Falls Prevention Frailty Pathway TECS

Reducing Urgent Admissions and Attendance One Team Teams can work together across organisations as ‘one’ team to improve outcomes Voluntary Sector Involvement Strength Based Approach Health and Wellbeing Centres Community Led Support Enhanced Care Planning Intermediate Care and Rapid Response Shared records Enhanced Health in Care Homes Framework Implementation of framework Scoping

Transforming Care at Home Efficient Discharge Discharge Co-ordination Supporting safe, appropriate and efficient discharge NHS Mail for providers Trusted Assessors Discharge Hub Discharge in-reach and out-reach Transforming Care at Home Improved outcomes and staff retention Self-Optimising Teams Recruitment and Retention E-platform