PLANNING FOR CARE CLOSER TO HOME
The Care Pathway Approach To make it easier for people to understand the different The ‘Pathway Approach’ defines how health and levels of care and treatment available, Joined Up Care social care teams will work in partnership with Derbyshire has developed a ‘Pathway Approach’. This one another, to assess a person’s needs, and put aims to both prevent people from going into hospital in place the right type of care and treatment that in the first instance, but also support people to return willcan enable regainour their confidence and You signthem up to to receive bi-monthly home, or close to home as soon as possible, should an newsletter independence to return to the place they call home by emailing karen.lloyd24@nhs.net inpatient stay be unavoidable. at all possible. orifyou can read past copies of our newsletter here.
Would you like to know more?
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I Can go Home (Pathway 0) A person can stay at home or return to the place they call home without further assessment. t ). You can System (ICS rated Care our website. yshire’s Integ h can be found on and Derb e’ whic for Derby Derbyshir the name Up Care yshire is to Joined Care Derb rs’ Guide Joined Up ‘Beginne on in our informati
April 2021
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I Need a Home Assessment (Pathway 1) A person can stay at or return to the place they call home with an assessment for community care and support needs, e.g. daily visits from a carer, or community nurse. I Need a Temporary Community Support Bed (Pathway 2a) Staying at or returning to the place they call home is not an immediate option for the person, so the person is discharged to a ‘community support bed’. This is provided in a residential home setting with 24-hour care available, i.e. assistance with daily living, like dressing and eating, but nursing care is not needed. The person is supported to recover and return to the place they call home as soon as possible. I Need a Temporary Community Derbyshire’s Integrated If you areNursing interested Bed in the(Pathway nuts and 2b) The same as Pathway 2a with the addition of 24 hour nursing and clinical support services as Care System (ICS) Explained bolts of how the ICS will work, please required. For example, the person has complex medical conditions that require the specialist read Guide Twocondition - “The Process”. knowledge of registered nurses, or a person’s medical requires monitoring.
Section Two – The Process
I Need a Permanent 24-hour place of care (Pathway 3) A patient requires 24-hour nursing care or a residential home providing 24-hour support which is likely to be a permanent situation subject to the continued assessment of needs. What is Derbyshire’s integrated care system? Derbyshire’s Integrated Care Systems (ICS) is called Joined Up Care Derbyshire (JUCD)
Contact Joined Up So how this work in practice? Caredoes Derbyshire and is a partnership that brings together providers (those who deliver services) and
One of the services being created to work in this way is ‘Team Up’ the community urgent response service. More information on the Team Up approach can be found here: https://joinedupcarederbyshire.co.uk/about/our-governance-1/team-up Onecan of the services being created to work in this wayCare is System This will be the biggest change in the way primary care You find more information about the Integrated here: Visit the website: is organised since the start of the NHS. General practice ‘Team Up’ the community urgent response service. More https://derbyshireinvolvement.co.uk/integratedcaresystem joinedupcarederbyshire.co.uk information on the Team Up approach can be found here. will join up with community providers, mental healthcare providers, adult social care and the voluntary and Email: This service aims to create a single team of community sector to put the patient at the centre and joinedupcarederbyshire@nhs.net professionals across health and social care who see all offer holistic care to meet their needs. the housebound patients in their neighbourhood. This When a housebound patient has an urgent care need, team will do all the urgent, planned, and anticipatory currently the service they receive is largely from the care for this group of people, to ensure that the right ambulance service or their GP. This person is usually thing is done at the right time by the right person. It’s time-pressured, and alone in their decision making, not a new service or an add on to an existing service, which can lead to them making the quickest and easier it’s a ‘teaming up’ of existing services that already decision to ensure the safety of their patient which exists – so Joined Up Care at its best. might not necessarily be the right decision. commissioners (those who plan and buy services) with other local partners to collectively plan health and care services to meet the needs of the local population. There are 42 Integrated Care Systems in total, which cover all parts of England.
The central aim of an ICS is to join up care across different organisations and settings to provide people with more convenient and personalised care for their health and
wellbeing. Working across NHS, local councils and other sectors, including the voluntary and community sector, the fire and rescue service, and the police, the ICS will tackle the
main causes of lower life expectancy within our communities and improve the things that contribute to healthy life expectancy during the course of people’s lives.
Publication Date: June 2021
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