The CCG has determined to assess and seek to resolve the needs of those with complex needs or vulnerabilities, including those living with frailty. This group represents a major commitment for the professional health and support services and once they are effectively provided for, time and skills will be released to serve the needs of the remaining members of the community.
This work is divided into three essential areas of focus:
- A way of working to identify and support the anticipated needs of those considered vulnerable or complex, including those living with frailty, all the way from a latent need in the community to hospital admission and discharge; thereby minimising the number who actually need hospitalisation.
- A group of initiatives designed to provide support and restoration of self-support in the community to those with vulnerable needs focussing on those discharged from hospital
- Making clinical information available at the point of clinical need in order to optimise the quality of clinical decisions proposed to the patient
North East Hampshire and Farnham CCG has established initiatives targeted to alleviate the problems confronting people recently discharged from hospital plus those who are striving to avoid hospital admission in the first place.
At the heart of the programme is a concept described as “Integrated Care Decision Making”, which is an approach and model of care designed to improve the physical and mental health, social care and wellbeing across all our adult population in the Frimley area.
Our CCG is presently organised into networks (Fleet, Yateley, Aldershot, Farnborough and Farnham).