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Delivering better services for people with long term conditions

Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013. Delivering better services for people with long term conditions. Paul White Programme Director, ProMISE programme NHS Bromley Clinical Commissioning Group paul.white@bromleyccg.nhs.uk.

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Delivering better services for people with long term conditions

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  1. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Delivering better services for people with long term conditions Paul White Programme Director, ProMISE programme NHS Bromley Clinical Commissioning Group paul.white@bromleyccg.nhs.uk Share your thoughts: #BASSCpromise

  2. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 What is ProMISE? A quick reminder! ProMISE stands for: Proactive Management of Integrated Services for the Elderly (and Vulnerable) Share your thoughts: #BASSCpromise

  3. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Our aims for residents in Bromley: • Promote independence • Identify health and social care needs at an early stage • Integrated working • Keep people well and at home • Improve value for money. Share your thoughts: #BASSCpromise

  4. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 What is integrated care? • Integrated care starts from the needs of the whole person. It is about: • Prevention of poor health through self care or expert patient programmes • Empowering people to make choices, together with health and care professionals • Intervening at an early stage before health problems such as long term conditions get worse • Maintaining independence • Providing more care at, or closer to, home. Share your thoughts: #BASSCpromise

  5. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Some of our projects: • Free Urinary tract Infection (UTI) training for carers • Risk stratification and case management • FLORENCE (FLO) award winning Simple Telehealth system • St Christopher’s End of Life Care • Falls and Fractures Prevention Service • Patient liaison officers in GP practices Share your thoughts: #BASSCpromise

  6. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Bromley Healthcare Rachel Street Operations Manager Bromley Healthcare rachel.street@bromleyhealthcare-cic.nhs.uk Share your thoughts: #BASSCpromise

  7. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Who are Bromley Healthcare? • Bromley Healthcare is a community interest company offering community health services to the NHS • This means any money we make or money we do not spend can be put back into services • Bromley Healthcare is run by everyone who works for us. Share your thoughts: #BASSCpromise

  8. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Share your thoughts: #BASSCpromise

  9. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Share your thoughts: #BASSCpromise

  10. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Case study examples Dr RuchiraParanjape Principal Clinical Lead NHS Bromley Clinical Commissioning Group Share your thoughts: #BASSCpromise

  11. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 A tale of two patients • Mrs Smith • 85 year old lady • Frailty and recurrent falls • Carer needs • Dementia • Chronic Kidney Disease • Poor eyesight • Presbycusis (Going deaf) • Mrs Jones • 87 year old lady • Frailty and marked weight loss • Carer needs • Alzheimer’s dementia • Chronic Kidney Disease • Diverticulosis: condition that affects the large intestine (colon). Share your thoughts: #BASSCpromise

  12. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Mrs Smith and Mrs Jones Mrs Jones and Mrs Smith have the same GP. She used clinical judgement to identify them as high risk patients and referred them for a detailed assessment by one of our Community Matrons, Sue. Mrs Smith was happy to work through a proactive care plan with our integrated team, with the support of her carer, including social care assessment, advice on benefits, a carers assessment and offered additional help through local voluntary organisations. Both Mrs Smith and Mrs Jones have similar symptoms but Mrs Jones declined the offer of additional support through the ProMISE programme. Mrs Jones’ husband was naturally concerned about the financial implications of accepting a package of care but would not allow the Community Matron to arrange for the assessments and support that Mrs Smith received. Mr Jones told the GP that his wife was becoming increasingly aggressive but that his two daughters would look after them and that they ‘did not need help’. One of the daughters has since given up work to act as a full time carer. They have called the GP out to the house twice as they feel worried that their mother is not being monitored. Share your thoughts: #BASSCquestion

  13. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Key questions What are your experiences of services – good or bad? How do we improve services? What’s missing from the services we currently offer? What can we do differently? How can we tackle health inequalities? Share your thoughts: #BASSCpromise

  14. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 What are the challenges in Bromley? NHS England believe that everyone with a long term condition, including those with mental health problems, should be offered a personalised care plan that reflects their preferences and agreed decisions. How can we ensure that we become dramatically better at involving patients and their carers and empower them to manage and make decisions about their own care and treatment? Share your thoughts: #BASSCpromise

  15. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Share your thoughts: #BASSCpromise

  16. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Share your thoughts: #BASSCpromise

  17. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Share your thoughts: #BASSCpromise

  18. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Share your thoughts: #BASSCpromise

  19. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 NHS England – A call to action • How can we support people with long term conditions to stay well? • How can the NHS and Local Authority work better together? • What other things could health and care services do to support people with their own care? • Do you have any further comments on your experience of local health services, either through personal experience, or where you have cared for someone else? Share your thoughts: #BASSCpromise

  20. Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013 Thank you! Share your thoughts: #BASSCpromise

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