1. Integrated Service Delivery Across the Whole Patient Pathway
Johan Holte
Consultant Physiotherapist
Sussex MSK Partnership

2. something truly outstanding

3. Drivers for change
Sustainability

4. What the Commissioners are looking for
Co-ordinated Care Approach
Right person first time
One-stop shop where possible
Rapid diagnostics
Referral to treatment times: 8 weeks
Direct Listing
SDM intrinsic to process
Supported self care
Rapid advice & guidance
Fitness for surgery + discharge planning
Shared Decision Making
Education & training
Rehab post-op
Cost reductions
IT solutions

5. Integration across multi-disciplinary teams Person-Centred self care
Shift activity from secondary care into primary and community
Outcomes that matter
Shift from a medico / surgical model to a bio-psychosocial model

7. Safe Effective Timely Patient- centred Efficient
Care that is respectful of and responsive to individual patient preferences, needs and values
Patient values guide all clinical decisions
No Decision about me without me
What’s the matter becomes – “what matters to you?”
Patient owned records
Mass customisation – “Markets of One”
Minimally disruptive medicine

8. Single Electronic Patient record, Service IT and Knowledge Hub
Integrated MSK Service
Primary Care
Single Electronic Patient record, Service IT and Knowledge Hub
Self Care
In-patient care
Presenting condition specific care pathways

9. Condition Specific Care Pathway
Self care
Personal Care Plan
Primary Care
In-patient care
Integrated MSK Service

10. Early intervention RA GP MDS on referral Triage
Triggers urgent appointment
Community clinic for diagnosis and treat to target