SaHF DMBC Volume 1 Edition 1.1.pdf - Shaping a healthier future

Domain Examples of delivery across NW London 2
Care planning
and multidisciplinary
care
Information and
communication
Integrated care across NW London embeds care planning and coordination,
and providers are being required to work in new ways to enable
this
Systems incorporating case management (e.g., Wellwatch, Hospital at
Home) are being embedded across NW London
Improved end of life care will embed care planning, clear pathways and an
end of life care register
Multi-disciplinary groups, aligned to networks of care, are in development
across all CCGs in NW London
Pooled budgets between health and social care enable multi-disciplinary
working.
Common and integrated IT systems (e.g., SystmOne, EMIS Web) are being
developed in CCGs across NW London
Virtual wards enable information sharing for admitted patients
‘Co-ordinate My Care’ enables the sharing of care records for patients in
the last year of life
Re-ablement, rehabilitation and rapid response teams share information
to ensure effective discharge planning.
8.5.7. Delivering out of hospital services
Central to the successful delivery of Shaping a healthier future is the successful delivery of
the eight CCGs‟ out of hospital strategies. Therefore, we are focusing on delivering new
services in line with these strategies.
In 2012/13, the CCGs began to deliver their out of hospital strategies, supported by NW
London-wide developments such as integrated care pilots and 111. Since consultation,
CCGs have progressed in their planning for 2013/14, and we can now provide detailed
intentions for next year that indicate there is further progress planned in 2013/14 that will
ensure we have the services we need to make Shaping a healthier future a success.
Appendix J contains the Commissioning Intentions. Please note, these Commissioning
Intentions are currently being updated and the latest proposals can be found on CCG
websites.
This will require investment, and we have developed our modelling since the consultation to
provide estimates of the revenue and capital needed for new services from 2013/14 to
2017/18.
Details of the progress made in 2012/13, the plans for 2013/14 and the planned investment
in out of hospital services can be found in Chapter 8e and Chapter 16. The implementation
of out of hospital care by each CCG is described in Chapter 16. In addition, an
implementation plan for Shaping a healthier future – including out of hospital services – can
be found in Chapter 17.
8a. Development of out of hospital plans in NW London 232