1. Keep Well Extension Programme Supporting a Patient Centred Agenda – delivery and pathways Tracey Gervaise, Health and Wellbeing Lead, Moray Community Health & Social Care Partnership

2. Supporting a patient centred agenda – delivery and pathways Working in partnership Developed and implemented a range of delivery models and pathways of care to support the core and vulnerable populations – over 54 delivery sites Patients Clients Staff Primary Care Community Pharmacies Aberdeen Sports Village VSA Carer Services Aberdeen city; Aberdeenshire & Moray Councils Criminal Justice Services Scottish Prison Service Integrated Alcohol & Drug Partnerships Benefit & Employment Services NHSG services e.g. healthpoint; Healthy Helpings; e-Health Mental Health Services 3 rd sector partner organisations

3. Supporting a patient centred agenda – delivery and pathways Approx 1000 staff have access to and knowledge of the opportunities to support patients - referral and signposting directories developed for each delivery area Increased access to holistic range of services and support for all who need it Over 200 staff trained from a range of disciplines to support and deliver Keep Well from a range of disciplines Health Behaviour Change, trained health and non health staff in techniques to support patients Partner organisations embedding elements or all of the delivery pathway in their processes Modernising Primary Care - “make the patient experience as personal, supportive and appropriate as we would wish for ourselves” Providing connect and use of other resources to support delivery e.g. Mobile Information Bus

4. Delivery and pathways – pioneering Collaborative approach - commitment of everyone developing, implementing and delivering Keep Well – change in culture and behaviour Learning from early implementation; adapting and improving our processes Demonstrated to colleagues how the programme can support health improvement activity Generated significant new activity increasing the range and number of deliverers and support for patients Increased partnership working within NHS Grampian and with voluntary and 3 rd sector partner organisations Increased access to a health check for patients in less urban areas Programme is helping to embed inequalities sensitive practice in primary care and other delivery settings

5. Delivery and pathways – challenges Time taken to put some pathways in place Underestimation of some of the constraints out with our control, which affected delivery timescales Predicting uptake of health check invites; pace of delivery can vary considerably throughout the year Achieving ‘targets’ against balance of other ‘targets’ to be achieved Workforce constraints Systems infrastructure connections internal and external

6. Delivery and pathways - opportunities Using the learning from Keep Well to help support - Health & Social Care Integration agenda Community Planning (SOA,10 Year and Prevention Plans) Public Protection agenda – National Strategy National Multimorbidity Action Plan – (Oct 2014) e.g. - deepening our focus on personal outcomes - adopting a co-production approach - supporting the assets of individuals and communities Modernising Primary Care Maximisation of joint working within NHSG services and partner organisations to deliver on and address health inequalities Further support people at the centre of their pathways Thank you