UNI are supporting SunWest Practice Based Commissioning Consortia to implement the Castlefields Integrated Care Model to improve care and quality of life for patients aged over 75 who have multiple long term conditions. The model enables a more individual level of support for this vulnerable group of patients, with the intention of preventing hospital admissions and reducing bed days through hospital in reach. The approach is based on a multi disciplinary team (including staff from both health and social care) working closely to improve the management of this group of patients across a practice population.
Practice teams are supported to use various methods to identify the patient group, including the EARLI tool, and to develop a register to ensure appropriate and timely follow up. The multi disciplinary nature of the team means that patients can receive the right intervention at the right time.
Over the next few months the participating teams will come together as a large group at least 3 times to see examples of best practice from other areas and to share ideas across teams collecting data along the way to demonstrate improved standards of care and more importantly improve independence and quality of life for these patients.
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