Whole Systems Complex Care in Airedale, Wharfedale & Craven

Descriptions

NHS Airedale, Wharfedale & Craven Clinical Commissioning Group (AWC CCG) has directly awarded an extended contract for the Complex Care service to the Airedale Partnership. The Complex Care service will •Improve the quality of care individuals, families and carers experience; •Ensure that the individual's physical, psychological and care needs (health and social care) are being met through the delivery of pro-active, coordinated and seamless care (integrated care pathways and an integrated approach to case management). This includes when their needs escalate and they are unable to self-care; •To deliver parity of esteem and ensure that low level mental health issues that may manifest as physical health problems are identified and managed appropriately. To ensure that the impact of diagnosis and treatment (physical health) on an individual's mental health are taken in to account and addressed; •To test the benefits of the new Personal Support Navigator/Personal Carer Support Navigator roles and the ability of providers to ensure that this critical role is embedded within care delivery (through a Memorandum of Understanding/Operating Framework); •Support and empower people to take control of their health, their care and their lives - connecting people to community resources, reducing the need for statutory Health and Social Care Services; •Enable people to live longer, healthier and independent lives; •Contribute to a sustainable model of health and social care that ensures the safe, effective delivery of care and support in the most appropriate settings; •Make efficient use of care resources to create capacity to enable the delivery of new models of care (e.g. self-care and prevention, Wrap Around, Enhanced Primary Care and other Health and Social Care Services); •Stabilise and reduce demand for acute services by reducing avoidable hospital attendances and admissions and facilitating timely and safe discharge; •Stabilise and reduce the need for complex care packages (e.g. residential and nursing care); •Deliver a high level of staff satisfaction (staff are satisfied with their place of work and the quality of care they provide); •Test the impact on the outcomes for individuals of adopting new and more pro-active ways of working, through a holistic, needs led, person centered model of care; •Utilise care data (e.g. risk stratification, acute data) and soft intelligence, to pro-actively identify individuals that are receiving high cost, inefficient care being delivered in a fragmented and uncoordinated way; •To test the adoption of new ways of working within the care system; •To test the culture change necessary to support and empower people to become active participants in their own health and wellbeing.