Programme Management Support and Facilitation for the role out and embedding of Place Based Care

ABUHB requires support from an appropriate organisation to support the development and implementation of a Programme that will result in patients and carers being able to successfully access information, advice and support within the community. This aims to reduce reliance on the unscheduled care pathway and to eventually reduce avoidable emergency admissions into secondary care. The system will create resilience and compassion within the local communities within Gwent. a) A full package of support is required to develop and embed an integrated system working across health, social care and third sector provision. This will be required over two Neighbourhood Care Network areas within Gwent, North Caerphilly and Blaenau Gwent. This package will be focused around expert facilitation and support for practices and wider community settings, enabling culture change to create compassionate communities which are, resilient, independent and less reliant on healthcare services. This will be tailored to ABUHB Transformational Model There will also be a requirement for the development and implementation of a robust communications and marketing strategy to increase public awareness about the new models of care. b) Support the development of sustained self-care within the community through the empowerment of patients and carers. Ensure that successful methods of signposting patients to sources of information, advice and support in the community to reduce demand within the unscheduled care system. Common examples include patient information websites, community pharmacies and patient support groups. The system must ensure that patients benefit from training in managing their condition, as well as connections to care and support services in the community. Required outcomes: - Programme management and governance arrangements will be required in the form of a Steering Group for compassionate communities and reporting to a Programme Board (potentially Clinical Futures Level 1) - Programme Manager to oversee delivery and ensure conversion of system to be supported through core funded roles by the end of March 2020. - Develop a full benefits realisation plan and map to illustrate anticipated outcomes - Development of clear measurable outcomes to demonstrate success - Improved access across primary care with reduction of demand in secondary care - Enhanced community wellbeing, reducing demands on packages of care and placements in Local Authority care home settings - Improved sustainability of Primary Care - Improved integration of Health and Social Care Services - To support the local population in terms of early intervention and prevention - Improve quality of Patient Experience - Improve education with self-management - Release capacity in GP Surgeries to enable Doctors to concentrate on planned care.