We have developed an approach and accompanying toolkit to support teams and organisations in the design and delivery of personalised, proactive care in line with the hospital to community shift outlined in the 10 year health plan.
This report and toolkit outline how the approach can work and curate key learning from our pilot work with two neighbourhood health teams in North Cumbria (Keswick and Solway PCN and Carlisle Healthcare PCN). The resources share key learning, practical advice and tools from the successful implementation of the pilot proactive care programme based on the Year of Care approach to personalised care and support planning.
The approach enables integrated neighbourhood teams to deliver coordinated, preventative healthcare to people with frailty and multiple long-term conditions, who are beginning to have more functional difficulties and are at risk of using unplanned care.
Please contact us for further information on bespoke workshops or training at enquiries@yearofcare.co.uk.