CHEADLE & BRAMHALL NEIGHBOURHOOD COMPLEX CASE MANAGEMENT WORKSHOP SESSION FOUR 15 SEPTEMBER 2015

Identification of people with complex needs Tools available RADAR Combined PARR EMIS web Other sources of information Team members Clinical system – number of conditions, Polypharmacy, Number of appointments Carers LA processes MAARS and MASSH Discharge from hospital TPA Care Homes Statutory services NWAS, fire, police, probation CHC assessments GSF meetings Blue Badge holders Disbility – sight, deaf, communication issues Falls – Care call Health and Wellbeing checks

Proposal The tools are used to establish an initial list. This is reviewed for suitable people as not all will be. The list will be augmented by additional information from other sources including the above A list is then held on the GP clinical system as the core from which to work

Management of people with complex needs Use of tools - PARR/Radar & info as above Funding Radar neighbourhood knowledge Prioritise - Traffic Light Prioritise - Traffic Light Weekly MDT Integrated Care Plan Integrated Team Wider Health or Social Care Services Key Worker Case Manager Key Worker Case Manager Third / Voluntary Sector Sub-committee Stockport Monthly Sub-committee Stockport Monthly Share with other neighbourhood Proposa l

Support required for this process MDT meeting funding Care Coordinator capacity and identification IT support to enable data gathering for MDT discussion, care plan development and management Virtual participation in MDT process Data analysis capacity Secretarial support to process Removal of referrals or other paperwork Medication review capacity Outstanding items Triage process Assessment process Prioritisation process Role of LPG (if required) Information on skill mix and capacity of community team Birthday checks link