1. System Transformation Plan Building a Sustainable Future
Better Together
System Transformation Plan
Building a Sustainable Future

2. Introduction Staff Workshops April 2012
Direction of Travel agreed and supported by Commissioners
Pilots/Trials
Professional leadership
Consultation
Next steps

3. Disease Management (20%)
A Tiered Model
to Prevention
Level 3:
Case Management (5%)
Home Improvement, Supported Housing, Home Support, Telecare, Aids and Adaptations, Healthy Diet, Social Support, Crime reduction, Benefits Advice, Carer Support, Exercise
Care/Case Management, Disease Management, Falls Prevention, Medicines Management, Expert Patient Programmes, Intermediate care, palliative care
Level 2:
Disease Management (20%)
Level 1:
Self Management (75%)

4. Risk Stratification Lasted until October
Regional solution has been withdrawn
Different CCG solutions
Good case studies of case management in localities – need to publish success more
Professional judgement – one size doesn’t fit all
Data governance, Capacity

5. Single Assessment Multiple Forms Professional judgement
Professional leadership
Relevant to practice / frontline trials
Record keeping
Simplified forms
Number
Size

6. Working Model

7. Remote Working Trials Computers Pens Social Care had greatest benefit
Health clinical system
Training
Cultural issues of real time recording with PC
Now handed over to IT

8. Next Issues Assistive Technology Workforce planning
Refining standard operating model
Productive series – wards, communities …
Patient led systems
Frontline led innovation shared across Trust

9. Conclusion Local solutions will be different
Advantage in sharing innovation
Transformation topics led by teams not centrally
Skill set not service