SCW has been commissioned to work with groups of practices to explore the opportunities of working collaboratively providing care closer to the person. The purpose is to identify and deliver new models of care focused on the needs of a population supported by harnessing the skills and assets within the community.
- Working with primary care to understand the care needs of the population through population health analysis.
- Developing an understanding of the non-clinical needs of people attending primary care services.
- Identifying providers of care in the geography – health, care and voluntary/charitable sector.
- Developing new models of care including signposting, care navigation and MDT approaches built on the needs of the population.
- We facilitate the development of care segmentation models to identify the needs of the population, using both primary care and secondary care data, and mapping it to illustrate geographically where those of greatest need reside.
- We undertake community-based mapping through both desktop research and on the ground interviews to identify providers of care and additional community resources (assets) in the geography.
- We arrange and facilitate stakeholder workshops to develop a shared vision for the population and explore opportunities to work differently to meet the needs of the population.
- We have developed impact measures across health and care using evidence-based reviews on the potential impact to support the development of a robust case for change and business plans.
- We support the implementation of digital, contractual and process enablers to support the delivery of new models of care.
- Having worked with three practices in Hampshire throughout this process, we have identified new approaches that will support people who currently attend general practice, but who present with no clinical issues or issues that arise from non-clinical matters. Using community-based assets to support these people appropriately outside of General Practice, we are enabling the clinicians to spend more time with those with more complex care needs.
- We are working through a CCG to use this approach to support their integrated care agenda, working closely with both health and social care. This approach has been instrumental in gaining Primary Care buy-in and leadership in this programme of work.
“Thank you for heading down this way to present to the Federation, they absolutely loved the concept and are fully on board – so much so that Dr Stradling has said she’d like to be the lead GP on the project and help champion the approach across primary care! Great to have buy-in on a practice level.”
S Turpin - Programme & Engagement Lead