effective/appropriate for the patient and discuss further with the appropriate GP. Cluster pharmacists to discuss To be undertaken and medicines wastage with carers to findings fed back to the retain (Pro Re Nata) PRN cluster routinely. medicines. To be undertaken and Prescribed nutrition drinks to be findings fed back to the reviewed for need and cluster routinely. effectiveness. 6 To address the complex To consider the provision of the Health Board Ongoing Collaborative working Cluster Uptake : care home enhanced service via / with other local health 7/8 Practices medical needs and to the cluster to those practices not GP Practices services throughout the provide an enhanced participating in the DES / Cluster primary care clusters to provision of care for Pharmacist / provide overarching residents in Care Assessments and regular reviews GP OOHs leadership of Homes. Delivering teams. of the mental and physical health treatment and of the residents services to ensure a Wraparound services decrease in unplanned provided for the patient, transitions of care and poly i.e OT, Podiatrist, pharmacy. Dental, Optometry, Audiologists, Dieticians, Mental health care. A decrease in Unscheduled admissions A decrease in Polypharmacy 7 To ensure, with the Health To consider the provision of the Health May 2017 Safer services through A GP has attended the Board, that all network enhanced service for oral Board, GP Bay cluster to present and not separating roles of patients have access to the anticoagulation with warfarin via Practices, discuss the proposed monitoring and
Cluster pharmacists to discuss medicines wastage with carers to retain (Pro Re Nata) PRN medicines. Prescribed nutrition drinks to be reviewed for need and effectiveness. effective/appropriate for the patient and discuss further with the appropriate GP. To be undertaken and findings fed back to the cluster routinely. To be undertaken and findings fed back to the cluster routinely. 6 To address the complex medical needs and to provide an enhanced provision of care for residents in Care Homes. Delivering treatment and services to ensure a decrease in unplanned transitions of care and poly pharmacy. To consider the provision of the care home enhanced service via the cluster to those practices not participating in the DES Assessments and regular reviews of the mental and physical health of the residents Health Board / GP Practices / Cluster Pharmacist / GP OOHs Ongoing Collaborative working with other local health services throughout the primary care clusters to provide overarching leadership of teams. Wraparound services provided for the patient, i.e OT, Podiatrist, Dental, Optometry, Audiologists, Dieticians, Mental health care. A decrease in Unscheduled admissions A decrease in Polypharmacy Cluster Uptake : 7/8 Practices 7 To ensure, with the Health Board, that all network patients have access to the To consider the provision of the enhanced service for oral anticoagulation with warfarin via Health Board, GP Practices, May 2017 Safer services through not separating roles of monitoring and A GP has attended the Bay cluster to present and discuss the proposed
6.%20%20Bay%203Yr%20Action%20Plan%2017-20%20Final%20Agreed%20Edited.docx