1. Name of presentation Greenwich Coordinated Care “Right care, right time, right place.” Pauline O’Hare – Health and Well Being Development Officer Jana Krohn – Integration Lead

2. Name of presentation Greenwich Coordinated Care Project Board: a cross agency partnership Aim to build on what works and to draw together primary, community, social and acute care services into one unified working model that is focussed on ensuring that people experience integrated care, designed around their needs, in the most suitable stetting.

3. Name of presentation Learning from National Voices to identify need – “I statements” I tell my story once The professionals involved in my care talk to each other. I am always kept informed about what the next steps will be 3

4. Name of presentation Early stages of long term conditions And health problems (24%) Early stages of long term conditions And health problems (24%) Multiple Long Term Conditions Other complex health & social care needs (8%) Multiple Long Term Conditions Other complex health & social care needs (8%) 2% Highly complex Frail, End of Life, social problems 2% Highly complex Frail, End of Life, social problems 2534 registered patients GCC – intensive assessment and navigation 19972 registered patients Community health & social care integrated teams (JET / CARS/ HID) 60094 registered patients GP care. Wellness, risk factor interventions 131339 registered patients GP care, Wellness, risk factors, social Health and Wellbeing group (16%) 39418 registered patients People experiencing inequalities or putting their health at risk (51%) The Greenwich Integration Christmas Tree

5. Name of presentation GCC Profile What does the hub look like? The Care Navigator is the main point of contact for the client and carer Monthly MDM for each GP practice Core team members are invited and other professionals as needed “I” Plan is developed at the meeting that is shared with client & all professionals involved.

6. Name of presentation GCC Integration Lead and Care Navigators Core Team Social Care Health Professional Clinical Psychology GP LTC Nursing Teams Falls Neurology Housing Model for Greenwich Coordinated Care Other council services Acute Trust Intermediate Care beds Drugs and alcohol Teams GAVS London Ambulance service Pharmacy Dietetics Grabadoc 6 Older People Mental Health Reablement Hospital Discharge Team (HID) Dementia Support worker GCC Network District Nurses Housing A & E

7. Name of presentation GAVS and wider VCS involvement / co- production Joint partnership from very early stages Attending multi disciplinary meetings and having an open line of communication Cultural change required with “I” statements A third of clients were involved with voluntary sector Social prescribing – community directory

8. Name of presentation Barriers / Learning Healthwatch interviews & managing scores – client satisfaction Staff experience - different skills and knowledge as well as an integrated care plan. Creating efficient and effective processes and systems Action learning meetings / flexibility between services A&E – AMP Voluntary services monitoring Criteria / funding for befriending

9. Name of presentation Social Care Needs

10. Name of presentation Contact details Greenwich Coordinated Care:  020 3049 0421  oxl-tr.Greenwichcoordinatedcare@nhs.net oroxl-tr.Greenwichcoordinatedcare@nhs.net Coordinated-care@royalgreenwich.gov.uk Greenwich Action for Voluntary Service:  020 8309 8231  www.greenwich-cvs.org.uk www.greenwich-cvs.org.uk