Coordinated care

Overview of coordinated care

Care coordination was developed as part of the work for our Local Care Network (LCN)  and is now one of the focus areas of Partnership Southwark. In 2017 we began delivering  coordinated care to people with complex needs; i.e. those people with three or more long term conditions (LTCs) to improve their health outcomes.

Why coordinated care ?

NICE published guidelines in 2016 which suggests optimising care for adults with multiple long-term conditions could reduce unplanned care such as emergency GP and hospital appointments. Coordinated care aims to improve quality of life by ensuring there is shared decision making based on what is important to each patient in terms of treatments, health priorities, lifestyle and personal goals.

What have we done so far?

  • We have talked to many patients with three or more long term conditions to support the development of coordinated care in Southwark. You can read about this engagement work here.
  • A local framework for delivering coordinated care and a patient pathway has been developed. The framework includes:
    • proactive identification of patients with 3+ long term conditions
    • holistic assessment of a person’s physical, emotional and social needs
    • proactive and person-centred care planning
    • improved multi-disciplinary working across all those involved in a person’s care
    • promotion of, and support for, people to self-manage their condition and improve their health and wellbeing.
  • Our LCN received a runner-up award at the Patient Experience Network National Awards in March 2018 for our engagement work around coordinated care. You can watch a short film of our Director Louisa Dove and Rosemary Watts, Engagement Lead at NHS Southwark CCG talking about how we engaged local doctors, nurses and patients to develop the coordinated care pathway in Southwark.

What difference has this made?  

  • From April 2017 to March 2019, 2477 patients with multiple long term conditions living in north Southwark received coordinated care which includes receiving a holistic heath assessment and a personalised care plan.
  • From April 2018 to March 2019 80 of the most complex patients were reviewed at one of our multidisciplinary team meetings.

What are our plans for the future?

  • We want to work in our neighbourhoods (Borough, Walworth triangle, south Walworth Bermondsey and Rotherhithe) so that we can build closer links with local community and voluntary organisations to support patients to manage their health and wellbeing.

Further information

You can watch a video by the Royal College of General Practitioners (RCGP) that shows how coordinated care will work in general practice.

Southwark Talking Therapies (IAPT) are running a series of self management classes and support groups for people with long term conditions. Please download the flyer  for further information.

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