The last 12 months
We have continued to grow and develop, offering a range of integrated services to meet the populations needs and the requirements of the Directed Enhanced Service (DES).
We have reviewed the pathway of cancer referrals within each practice, including, reviewing what type of cancers have been diagnosed and how the patients presented, looking at any similarities that the practices’ share, and what can be done by the practices to mitigate this.
Our workforce has continued to grow, including the Proactive Enhance Assessment Care Home team (PEACH), the Care Home Visiting Service, Health & Wellbeing Practitioner, Clinical Pharmacist, and Dietitian.
We have worked collaboratively with the Neighbourhood Team, offering a wider cover of services in an integrated way. This is to ensure people with the most complex health and care needs are proactively supported to live well at home, or as close to home as possible, using a ‘what matters to me’ approach alongside Comprehensive Geriatric Assessment. Within this group there is a large cohort of frequent flyers and high intensity users of all services which requires working with people from all sectors.
As part of the Towns Fund Bid, the Neighbourhood Lead and Clinical Director of the PCN are on the core stakeholder group to support the co-production of the campus for future living over the next three years. The PCN is awaiting more information regarding the towns fund college proposal for Skegness.
The next 12 months
To promote a personalised approach to care involving the communities we serve and building on the current assets. This includes the development of community gardens where we will be able to ‘Prescribe a Plant’ for patients who are then able to go out and join the community garden to improve their mental and physical health.
A clear vision, mission statement and values are to be established as we work towards the Integrated Care System (ICS).
What we are most proud of
The development of the core teams, their approach and ‘can do’ attitude in a collaborative manner working under a management matrix. Stakeholder relationships being built through co-production, Plan, Do, Study, Act (PDSA) cycles, flat hierarchy and recognising the pivotal role domiciliary care colleagues play within the multidisciplinary team (MDT) setting.
The Palliative Care Huddle has reduced duplication, it’s offered a platform for clinical supervision, shared skill mix and provides proactive care as opposed to reactive care.