Improving care for people at home or close to where they live
We are working together across health and social care services to improve care for people in their own home or close to where they live. This is called local care.
Our aim is for people to receive high quality, coordinated care that is easy to access and helps them to stay well and live independently for as long as possible.
To achieve this, we have identified eight key ambitions to deliver person centred care, which we’ve called the Dorothy model.
Each area across Kent and Medway has developed a local care plan based around the Kent and Medway framework (Dorothy model), supported by the STP. Older people who are frail and those with complex conditions are the first priority and in the longer term we will focus on improving care for children, people with mental health illnesses and those who are mostly healthy.
This video shows how health and social services in east Kent came together to improve local care services for their patients.
What we have achieved so far:
Supporting people to stay healthy and independent
Social prescribing and community navigation is being introduced across Kent and Medway as a way to keep people well and independent by connecting them to community based support and services.
Community/care navigators – they are the first point of contact for individuals, carers and health and care professionals, linking them to local services across the NHS, social care and voluntary sectors.
Social prescribing – this service supports people with social, emotional and practical needs by connecting them to social activities and helping them to make changes in their life to improve their health and wellbeing.
A free Help4Carers app is now available for Carers. This simple-to-use tool includes advice, guides, training and local service information.
In this video Roy tells his story about how Connect Well, a social prescribing project in East Kent, supported him after the death of his wife.
Keeping people safe at home
Coordinated care for people who need it
Multi-disciplinary teams (MDTs) – colleagues from the health, social and voluntary sector are working together in multi-disciplinary teams to share expertise and deliver more coordinated care for patients. Each patient has an individual care plan based on their needs and wishes.
MDTs support the primary care networks which are groups of GP practices working together with other health and social care professionals. You can find out more on our primary care page.
This video explains the role of multi-disciplinary teams and how they work:
We have developed a Local care multi-disciplinary team framework (1 download) with a set of standards and guidelines for primary care networks and Top tips for multi-disciplinary working (15 downloads)
Single point of access
Access to urgent care within two hours
Timely return from hospital
“We have found MDTs a massive help in getting everyone working together to achieve the best outcomes for people affected by dementia.”
Katie Antill, Joint Interim CEO, Alzheimer’s and Dementia Support Services
“I look forward to the gardener’s visit. The befriender is working well. My confidence is increasing and I go out for lunch once a week.”
What’s happening now
In some parts of the county, the local care model is well advanced, while in some areas it is in the early stages of development.
Here are some of the areas we are working on to improve local care in 2019/20:
- ensure the MDTs are up and running effectively across Kent and Medway
- develop models of care that deliver all the eight ambitions set out in the Dorothy model, which include urgent care within two hours and timely return from hospital
- embed the dementia pathway into the Dorothy model
- increase the number of individuals who have an integrated care plan
- start work on an MDT model for children with complex needs and adults with learning disabilities and autism
- ensure the social prescribing and community navigation services are being delivered effectively in all areas
- build on the support available for paid and unpaid carers by further developing the Help4Carers App.