Delivering Integration Together

The development of integrated care will aim to ensure services are delivered together, linking in a range of care services to provide local people with a better experience. The development of an integrated care system for those people who are aged over 65 with one or more long-term conditions will focus on:

  • Prevention
  • Early intervention
  • Maximising independence through the delivery of the right service at the right time
  • Optimising patient choice and control

The long term vision of local health and care services is that through an integrated strategy, within five years, patients will see a transformed health and care system where there is:

  • Early detection of long term conditions
  • Support to ensure that patients are empowered to manage their own condition/s
  • A proactive approach to identify people at risk of needing an increased level of care to ensure appropriate support is in place before a crisis situation occurs
  • The right care delivered at the right time through primary care, community services and the third sector working together in ‘Dedicated Core Care Teams’
  • Coordinated Care through services being delivered by multi-disciplinary teams holding regular case conferences and from having co-located teams
  • Personalised care planning with access to appropriate specialist support in the community
  • Supported hospital discharge to ensure that patients are only in hospital when they require an acute episode of care