Integrated Care – Adults & Older People Drivers for change: >65s represent 8% of total population Premature deaths from coronary heart disease (CHD) higher than in London as a whole Recorded prevalence of hypertension is increasing Death rate from Chronic Obstructive Pulmonary Disease (COPD) in Hackney is high Overall objective: Improve integration of health and social care provision, supporting residents to remain healthy and independent for as long as possible 12 Actions/changes proposed HUHT to deliver 2.5% efficiency requirement as part of the transfer of Community Health Services to HUHT Joint review of intermediate care and re-ablement services; inc exploration of a new integrated model with a single point of access Implement new pathways for asthma, heart failure, hypertension and tuberculosis in primary care Commission COPD Team to work with GPs in the management of patients following discharge from hospital Commission further consultant case reviews of diabetes patients with complex needs Continue to implement education programme to support GPs with management of patients with CHD Develop effective psychological intervention services and a key worker role for sickle cell patients Outcomes Quality Timely discharge; reduce length of stay Reduce admissions to residential/nursing home care Reduce A&E attendances and short stays in hospital FinanceNet savings of £1.3m in 12/13
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