Integrated and coordinated care

Key Aims

• We will redesign to provide more efficient, integrated services providing coordinated care at home that will enhance the experience of the people who use services and their carers.
• We will work to bring together health and social care teams and the Third and Independent sectors to provide the right level of support at the right time, to meet individual needs and reduce avoidable emergency admissions to hospital.
• We will work to provide coordinated health and social care services to better meet the needs of people requiring care at the end of their lives, and their families and carers.
• We will work with General Practice and the Out of Hours services to deliver more joined up responses ensuring there is a named person for GPs to contact for care coordination.
• We will create a structured, coordinated and strategic approach to community support for people with frailty, including dementia, and their carers to ensure that they remain in the community for as long as possible.
• We will ensure that quality of life and wellbeing is the main focus for health and social care services for people with long-term and life-threatening conditions, and that services work effectively with people at end of life to ensure their needs are met.

What we intend to do

• We will continue to develop of an urgent response service for acute care within the community and provide ongoing support for people to recover in their own homes wherever possible following an acute illness. This will include for example: Care and support redesigned to provide a more joined-up service at a local level working with communities to integrate care around clusters of GP practices and other community providers
• GPs being able to request an urgent response that could include Hospital at Home as well as wider Intermediate Care services , extended out-of-hours services and moving towards availability up to 24 hours over 7 days if this is supported by evidence
• For those who do not require hospital care, but are initially unable to go home to recover, a bed-based intermediate care provision will be further developed. This will include exploring opportunities within the new housing and care home facilities planned for Kirkcaldy, Glenrothes and Lumphinnans to identify different options for the local population

Impact of what we intend to do (2016-19)

These actions will support and demonstrate progress on:

• Reduction in use of acute hospital resources and the need for community hospital inpatient care with the potential to re-provision community based services
• Increased primary and community care capacity through integrating with intermediate care services and improved co-ordination across the whole system