Our vision for the Connecting Care in Cheshire Programme is that within three years the residents of Cheshire will enjoy a better standard of health and wellbeing. This is hoped it will place less demand on more costly public services through the implementation of ground-breaking models of care and support based on integrated communities, integrated case management, integrated commissioning and integrated enablers.
We are committed to ensure that individuals in Cheshire stop falling through the cracks that exist between the NHS, social care and support provided in the community, and we will avoid:
- duplication and repetition of individuals experience, with people having to re-tell their story every time they come into contact with a new service;
- people not getting the support they need because different parts of the system don’t talk to each other or share appropriate information and notes;
- the “revolving door syndrome” of older people being discharged from hospital to home not personalised to their needs, only to deteriorate or fall and end up back in A&E;
- home visits from health or care workers are not coordinated, with no effort to fit in with people’s requirements, and;
- delayed discharges from hospital due to inadequate coordination between hospital and social care staff.
Every community in Cheshire is different and local solutions will reflect local challenges but our action will be united around four shared commitments…
Individuals will be enabled to live healthier and happier lives in their communities with minimal support. This will result from a mind-set that focuses on people’s capabilities rather than deficits; a joint approach to community capacity building that tackles social isolation; the extension of personalisation and assistive technology; and a public health approach that addresses the root causes of disadvantage.
Integrated case management
Individuals with complex needs – including older people with longer term conditions, complex families and those with mental illness will access services through a single point and benefit from their needs being managed and coordinated through a multi-agency team of professionals working to a single assessment, a single care plan and a single key worker.
People with complex needs will have access to services that have a proven track record of reducing the need for longer term care. This will be enabled by investing as a partnership at real scale in interventions such as intermediate care, re-ablement, mental health services, personal health budgets, drug and alcohol support and Housing with support options.
We will ensure that our plans are enabled by a joint approach to information sharing, a new funding and contracting model that shifts resources from acute and residential care to community based support, a joint performance framework, and a joint approach to workforce development.