Keep Well Extension Programme Supporting a Patient Centred Agenda – delivery and pathways

1. Keep Well Extension ProgrammeSupporting 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 Primary Care Aberdeen city; Aberdeenshire & Moray Councils Community Pharmacies NHSG services e.g. healthpoint; Healthy Helpings; e-Health Patients Clients Staff Benefit & Employment Services VSA Carer Services Mental Health Services Aberdeen Sports Village Criminal Justice Services Scottish Prison Service 3rd sector partner organisations Integrated Alcohol & Drug Partnerships

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 3rd 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