A person centred, outcome focused, coordinated service What it will mean for you? Patient and Carer Provider Staff GP What are the programme benefits and outcomes?

Better Together Programme Benefits and Outcomes Programme BenefitsProgramme Outcomes People can access and trust consistent, accurate information and advice People can get coordinated help in arranging support Avoid repeat use of services; minimise duplication and re- admission Reduced need for hospital and high cost services Reduced avoidable emergency hospital admissions Increased effectiveness of preventative reablement and rehabilitation services Enable people to live independently and well (dementia diagnosis) Increased number of people being supported to live at home Improved use of assets Improved cost effectiveness and reduced unit-cost of services People are better supported in their caring role Timely care and treatment (reduce delayed transfers of care) People are safeguarded and treated with dignity and respect People experience a wide range of high quality services Services provide good value for money Skilled, capable flexible, integrated workforce A Total system costs reduced (5%) B People have independence, choice and control. C Resources are used efficiently and effectively. D People are better able to help themselves. E Joint resource planning responds to need and local people priorities. F People experience better outcomes through safe, quality, coordinated care. G Informal support maximised, caring for people at home. H Capable, sustainable and motivated workforce All the Better Together benefits and outcomes are met in full or in part by introducing these new integrated health and social care teams across the 13 localities in Dorset

Person First Information and Advice Care Co-ordinator (one point of contact ) Treatment, support and review End of life care Independent Living Tell my story once Choice and Control Patient and Carer

Tell My Story Once The Team will: Assess us once taking account of all of our needs. Use one care record that is shared with all professionals involved with our care. Provide one point of contact for all enquires, including out of hours, crisis and emergency. Treat us with dignity and respect. Work with us to develop a personalised care plan. Design services around our needs, wants and desires.

Person First The Team will: Allow us to have as much or as little support as we choose. Provide us with sufficient information and advice so that we can help ourselves. Provide us with a care coordinator who will be our main point of contact and who will work with us to create our care plan and coordinate our care. Treat me at home or as close to home as possible.

Treatment, Support and Review The Team will: Help us make the right choices about my care. Help us to better understand my condition, what to expect as it gets worse and how to manage it effectively. Allow us, with help from our care coordinator, to determine the review period of our care plan.

Treatment, Support and Review The Team will: Provide us with quick and effective support should I suffer a crisis or emergency out of hours. Use one electronic care record which can be accessed/shared by all people involved with my care. Discuss my care plan at regular team meetings and if changes are proposed, talk to us about them before changes are made. Provide me with a copy of my care plan and in the format of my choice.

Information and Advice The Team will: Guide us to trusted sources of information and advice and help us to understand and utilise it effectively. Help us make choices based on the information available including equipment and house adaptation support. Help us to access specialist advice including financial and personal budgets so that we can use our personal budgets wisely.

Information and Advice The Team will: Provide us with information about local voluntary and community groups, schemes and clubs which we might like to join or make use of (gardening, shopping, befriending services). Use one care record that is shared by all people involved in our care. We will be given a copy of the care record that will be in the format of our choice. Provide us with one contact number to ring when we need advice and support or when we suffer a crisis or emergency.

End of Life Care The Team will: Support us to make decisions about my care, especially should my condition(s) deteriorate. This includes a review of medicines. Support my carer by providing advice and support in financial, legal and other related matters. Support and have early discussions with the family to make sure options are discussed and decisions are made prior to my condition reaching its final stages. Allow me to die at home should that be my choice.

Choice and Control The Team will: Consider our goals and aspirations when creating our care plan. Work with us and other professionals involved in my care to make sure any appointments made are achievable and convenient for me. Help us to make contact with voluntary and community groups that may be able to help me live more independently at home. Provide us with one point of contact where we can seek advice and support about my care. Allow me to take charge of my care, to have as much as or as little support as I need, as long as it meets an appropriate level of care.

Independent Living The Team will: Deliver care services and treatments at home or as close to home as possible. Help us to use assistive technologies. Provide me with appropriate equipment and home adaptations. Provide us with information to help us make choices about my care.

Independent Living The Team will: Provide information and support from voluntary and community groups (advocacy). Support us through training, advice and support to minimise the risk of falls and errors in medication. Provide us with a care coordinator who we can contact should we have any concerns or questions about my care.

Care Co-ordinator The Team will: Provide one person to act as my care co-ordinator This person will: Be the main point of contact for all of our enquires. Work with us to provide the care and support we need. Liaise with the team to ensure continuity of care. Stay with us for the duration of my illness.

Care Co-ordinator This person will: Represent us at team meetings and care conferences. Work with us to review and amend my care plan as my conditions change. Co ordinate my care with all other professionals involved in my care plan.

Access to one electronic record Pooled budgets and resources Common Assessment Care closer to home Working as a single team Provider

Access To One Electronic Record The Team will: Use one record which can be accessed by everybody involved with a person’s care, including crisis, emergency and out of hours. Conduct one assessment reducing repetition. Be able to update records quickly reducing delays and errors in service delivery including medication.

Pooled Budgets and Resources The Team will: Be able to access multi disciplinary services quickly and efficiently. Be able to provide a more responsive service, with less delays. Be able to provide a wider selection of services through improved relationships and named links with voluntary and community groups and specialists. Be able to provide continuity of care without a break in service should the care coordinator go on holiday or be absent from work. Be able to identify risks early and focus on prevention, reducing costly interventions (ie hospital admissions)

Common Assessment and Co-ordinated Care The Team will: Work with the GP and local Practice to identify early, people in the community who may be at greatest risk. Allocate a care coordinator and visit the person to carry out one assessment which will consider all of the needs of the person and their carer. Have access to Joint Care Planning. Work with the person and carer to develop a care plan and care record that can be shared easily with multi-agencies.

Common Assessment and Co-ordinated Care The Team will: Be able to share decision making through regular team meetings and care reviews. Have named links with specialist services making access easier and quicker. Have named links with local voluntary and community groups broadening the range of services available. Have a copy of the person’s care plan in the format of their choice.

Care Closer To Home The Team will be able to: Provide treatment in the most appropriate setting to meet the person’s needs. Enable the team to identify risks early and provide early interventions. Encourage colleagues to develop and work with the wider local and community groups to support people and to develop outreach services.

Care Closer To Home The Team will be able to: Encourage people to help themselves and to maintain a more independent lifestyle for longer. Delay, through early intervention and risk management, the need for costly hospital admissions and readmissions. Reduce the potential for a crisis or emergency situation to develop through good communication, advice and support

Working as a Single Team The Team will be able to: Adopt a multi-disciplinary approach to providing care services. Consider the whole person’s needs and use expertise from within the team to effectively manage a person’s condition. Reduce duplication and reduce costs by working as a team, sharing information, expertise and effort. Make decisions more quickly and react more effectively to any change in the persons’ condition or needs, reducing the risk of an unnecessary and costly hospital admission.

The Team will be able to: Access specialist services quickly through named links who will be able to react quickly to a request for support or provision of a specialist service. Provide a member of the team to act as a care coordinator and to provide continuity of care by ensuring that person remains as the main point of contact with the person and their carer throughout their illness. Use and access one care record and hold regular team meetings placing the patient’s needs first. Ensure continuity of care by covering absences of staff members quickly and efficiently. Working as a Single Team

Improved communication and collaboration Increased Job satisfaction Simplified Management and reporting Increased Personal development More Responsibility Staff

Improved Communication and Collaboration The Team will: Work together to provide a co-ordinated and consistent approach to care provision. Share information, use common processes including a common assessment, and use technologies that can talk to each other. Hold joint team planning and review meetings where each care plan is discussed, making sure care provided is appropriate and meeting the needs of the person and their carer.

The Team will: Report to a single line manager simplifying and speeding up the reporting and decision making process. Be able to cover for each other should a member of the team, or a care coordinator, be absent from work. Use one care record that can easily be shared between professionals involved with a person’s care. Improved Communication and Collaboration

The Team will: Be transparent, focusing on the patient and the care they want and need. Have increased influence and work with the voluntary and community groups. Have increased access to information and advice for patients and their carers. Have increased access to specialist services through named links.

Increased Job Satisfaction Working in an integrated team will help us to deliver a better service and improve our job satisfaction because we will be able to: Have greater access to shared assets, resources and peoples experiences. Respond quicker to a person’s needs. Learn from other members of the team, developing our skills, knowledge and experiences. Attend joint learning and development opportunities that will help us to become a more rounded clinician/expert. Become a care co-ordinator and develop a long term relationship with the people we care for, to help make a real difference to their lives. Have greater authority to make decisions.

Increased Job Satisfaction Working in an integrated team will help us to deliver a better service and it will improve our job satisfaction because we will be able to: Have people to turn to should I need advice or assistance. Have a manager who trusts me and who will support me to carry out my role to the best of my ability. Help people stay at home for longer if that is what they want. Have greater responsibilities and challenges.

Simplified Management and Reporting The team will be able to be more responsive to a person’s needs because it will have: Access to a team of experts whose strengths can be called upon to gain valuable insights, advice and support. Greater authority to make decisions about a persons care and to feel supported and trusted by their manager. A single line manager. A common assessment form/process which is understood by all professionals in the team. A care record that can be shared and accessed by all professionals involved with a persons care, including emergency/out of hours care.

Increased Personal Development Working as a team will provide us with opportunities to: Learn from others, broadening our knowledge, skills and experiences. Attend joint training courses. Develop into a more rounded practitioner, able to confidently provide advice on a number of issues which are not within our normal professional area of expertise. Increase my awareness of other roles within the Health and Social care sector, that I may like to explore

More Responsibility Working as a team will mean: We have greater authority to make decisions. We will gain in confidence. We will feel trusted by our manager and team. We will be able to have a greater impact on the people we care for.

Early Help and support Joint care Planning A more responsive service Electronic Record Improved communication and collaboration Person First GP’s

Early Help and Support The GP will work with the team to: Identify patients early who may be at greatest risk. Arrange for an early assessment to be made. Provide support to prevent patients condition(s) deteriorating. Work with the patient and their carer to put into place a comprehensive care plan. Provide one point of contact through a care co-ordinator.

Early Help and Support The GP will work with the team to: Link with specialists and voluntary and community groups whose help maybe needed later. Provide advice and support to patients and their carers so that they are better able to understand their condition(s), what to expect and who to contact should they need help. Provide advice and support to minimise occurrence of a crisis or to help them understand how to minimise a fall, errors in medication and other incidents that might require further intervention.

Joint Care Planning The GP will work with the team to: Develop a personalised care plan that meets all of the needs of the patient and their carer Regularly review a patient’s care plan to make sure it meets the patients current needs. The GP and the team will work together to react quickly to: Amend and adapt the care plan should the patients condition deteriorate.

Joint Care Planning The GP and the team will work together to react quickly to: Provide the patient with information and advice to help them look after themselves and minimise crisis or emergency. Provide a quick and responsive service should a crisis or emergency occur. Provide an electronic care record that can be used by all other professionals involved with their patients care.

Joint Care Planning The GP and the team will: Link with voluntary and community services that may be able to help the patient live a more independent lifestyle. Link with and maintain relationships with other specialist services so that their help can be accessed quickly and efficiently. Have and maintain direct and in-direct contact with patients through more information, communication and collaboration.

A More Responsive Service The GP will work with the team to: Deliver a service that can react quickly and effectively 24/7; 8 am to 8 pm through the team and out of hours through a single point of contact. Deliver a personalised service where the views and wishes of the patient and carer are listened to first. Make sure any crisis or emergency especially out of hours is responded to quickly and is followed up afterwards. Provide a service which minimises risk and helps to reduce further crisis by making sure routine and preventative interventions are carried out effectively. Provide a service that will provide greater access to voluntary and community groups, advocacy and minimise social isolation.

Electronic Record The GP and the team will provide a service that: Uses an electronic care record that can be accessed and shared with all professionals involved with a patients care. Is transparent in nature; where the patient and all those involved with their care are kept up to date and informed about their condition and needs as they change. Has IT systems that can talk to each other and use processes that are multidisciplinary, agreed and used by the whole team.

Person First Patients will: Have direct access to the GP as normal, but patients aged 75 and over will have a named GP. Have greater access to the GP through the Care co-ordinator and integrated team, allowing them to react quicker to requests, events, crisis and emergencies. Have greater visibility of a patients condition and needs, through the care record, reducing delay and duplication. Be able to put the patients needs first, through a personalised care planning approach, a persons needs, wants and desires will be listened to.

Improved Communication and Collaboration The GP will work with the team to: Make sure a persons care is the first priority, everything else is secondary. Make sure everybody involved with a patients care is kept informed about developments. Make sure crisis and emergencies are followed up quickly to establish cause and effect and to put in place measures to minimise reoccurrence.

Improved Communication and Collaboration The GP will work with the team and will: Hold regular team meetings to discuss case load and care plans. Maintain named links with specialist and other services so that action when needed, can be taken quickly. Develop a personalised service through the care coordinator who will be able to keep the GP and the team informed about a patients care but also be able to act quickly to events.