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.

This video about the Healthier Fleetwood Primary Care Home is a great example of local care in practice:

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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.

Android: https://play.google.com/store/apps/details?id=uk.nhs.helpforcarers

iOS: https://itunes.apple.com/gb/app/help4carers/id1451819431?mt=8

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

 

Health and social care professionals are working together to help people stay safe and remain independent in their own home. Services include falls prevention, specialist aids and adaptations and home support with personal care.

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:

MDT poem from Kent Community Health on Vimeo.

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

 

Patients have one point of contact, whether that is a key worker or a single contact number should they wish to contact their MDT about their care.

Access to urgent care within two hours

 

Patients who suddenly become unwell will be seen and treated in their own home within two hours to avoid, where possible, having to be admitted into hospital.

Timely return from hospital

 

Care is put in place for patients on their return home from hospital to help them recover more quickly.

Supporting services

Access to tests and diagnostics – patients and health professionals have better access to expert opinion and diagnostic services, including x-rays and blood tests, and get the results back in a timely manner. 

Multi-disciplinary working

“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

 

Social prescribing

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.