What was the issue you were addressing or working on?
Demographic change, an ageing population and increasing incidence of long-term conditions and co-morbidities and the need to develop co-ordinated responses across primary health, social and specialist care.
What you did?
Fundamental re-design of Rehabilitation and Enablement Services. Established three integrated multi-professional teams aligned with groups of around five general practices across adult services in East Renfrewshire. Teams established following extensive engagement process. Teams are accessed via a single point of access with cluster action teams directing response to appropriate professionals. Teams include staff from social work, occupational therapy, rehabilitation, community nursing, business support. Each team also includes an advanced nurse practitioner.
What were the outcomes - benefits or otherwise?
Benefits realisation relates to getting the right care in the right place at the right time for people with health and social care needs. The cluster model is, at the time of writing, in its first year of full implementation. Early results indicate that the model is working well and improving relationships, care co-ordination and is producing positive personal outcomes. There is a strong focus on Talking Points – Personal Outcomes, anticipatory care, long-term conditions management, preventing unnecessary hospital admission and supporting people at home or in homely settings.