Whole Systems Integrated Care in Brent

Descriptions

NHS Brent Clinical Commissioning Group (Brent CCG) has directly awarded the contract for WSIC service to the new partnership of the Brent GP Network Collaborative. The Whole System Integrated Care (WSIC) will provide functions and services that support the coordination and integration of care for adults with long term conditions. Patients will be identified through GP registered lists in Brent and WSIC operates out of Primary Care, organised around the relationship between the GP and their patient. The overarching objective is to keep vulnerable people well in the community. The Brent GP Network Collaborative will undertake the following: a) Risk stratification and case finding - from the GP registered lists (cross-referenced with partner caseloads). b) Proactive care planning – care planning, goal setting, crisis planning and review for patients most at risk, in need or unstable. c) Multidisciplinary case management – an enhanced mainstream care offer for care planned patients, with more intensive case management for a subset of this group as required. d) Support to self-care: I. administration and use of a new patient activation measure – with results used to support the tailoring of care plans and care delivery; II. recruitment and piloting of Care Navigators working with GPs and colleagues to support patients and carers to access voluntary and community support in line with their self-care goals and care plan; III. staff training for GPs and colleagues in techniques such as Coaching for Health and Motivational Interviewing. e) Development of multidisciplinary team working – alignment of team leaders from social care and district nursing. Inclusion of mental health and of voluntary and community sector representatives. f) Weekly Complex Patient Management Groups (CPMG) – case management meetings hosted by each Network’s Core Team with the participation of team leaders from Social Care and District Nursing. g) Monthly Multidisciplinary Group meetings - hosted by and within each GP Network with the participation of individual GP practices, CPMG members and specialists as required. h) Care Plan review – regular review and review in response to trigger events by the patient’s own GP, with onward referral and case management as required. i) Development of the operational management model – GP-led model of clinical supervision and governance; standard operating policies and procedures rolled out across Primary Care; management and analytics/ information function with access to primary care data for shared quality monitoring and performance reporting. j) Development of integrated health & social care data – production of a patient-level Integrated Care Record and use of this and other tools & dashboards produced by a new linked dataset with an agreed consent model led by the patients GP.