Outcomes & actions of integrated care meeting in GWR, hounslow

Here is a summary of our Great West Road locality (Hounslow) integrated care meeting discussed on the 9th December 2014. It was a short but productive meeting. Outlined below.

  1. Brief recap of WSIC (Whole System Integrated Care) and discuss outcomes of the Simulation event – discussed ways in which we can access advice from the providers for individual patients, when we need it. We discussed the use of social media in healthcare for our locality in delivering integrated care. A quick summary of what happens elsewhere, we are ahead of the game (although it often does not feel like it!). For more info, click here. 
  2. Update on Locality pathfinder – a presentation from Phil Howell from London Borough of Hounslow, A really helpful update on the progress and key lessons learnt in the pilot between Hounslow CCG and London Borough of Hounslow to identify ways in which we can work collaboratively. This pilot is running in Great West Road and Feltham localities in the first instance. For more info, click here
  3. Workforce and training issues for staff delivering integrated care. Verbal presentation by Natalie Oswald, Northwest London. Discussed CEPN (Community Education Provider Networks) – major issue, probably the biggest rate limiting step for implementing WSIC. We will work on identify learning needs as providers (primary, secondary and social services) and see if we can collaborate with joint external training, develop internal training teaching, mentoring / coaching within our locality etc. Dementia is an obvious one to start with. For more info, click here. 
  4. Setting up locality patient forum, increasing patient engagement and education. Verbal update by Rob Flan. We would like to develop assessments of patient educational needs and help them to own and improve their health outcomes. Explore community and self directed learning rather than the traditional didactic approach taken with patient education. Combination of online and meetings.

It was a busy meeting but please feel free to continue to conversation here.

Key themes that emerged are

  • Develop a single care record
  • Reconciling accountability with the nominated care coordinator. Having clear points of contact.
  • Building up trust between providers and patients. Understanding each others roles eg sitting in on each others clinics.
  • Improving communication between providers, develop a contact list, physical meetings, phone calls, conference calls (video & telephone), including contact with patients. Social workers have already started ‘drop in clinics’, which have had positive initial feedback. These will be extended and offered to other practices.
  • Streamlining referral process between providers
  • Getting feedback on referrals made. Clear summary of has been done and what the person who has received the letter needs to action. Social workers will start trialling this now.
  • Review existing resources of all providers and identify ways in which we can streamline them improve service we provide for patients and avoid duplication.

MDG meeting