No Objective Key Key partners For Outcome for Progress to RAG Actions completion patients Date/Current Rating by: - Position 1 Bay cluster to work To agree clear eligibility criteria Health Board / March 2017 Better sign posting LACs have attended network meetings to closely with Local Area in order for practices to refer Practices / Local Area to services that can introduce themselves Coordinators suitable patients Coordinators meet patients social to discuss the project needs follow up work will To assist in the promotion of include linking to the Local Area Coordinator projects Early Adopter Pilot. in relevant practice areas 2 To continue to support the To act as a key stakeholder in Social Services, March 2017 and More effective, Updates are regularly received at development of integrated informing the ongoing community nursing, ongoing timely and network meetings health and social care development of integrated third sector, primary health and with opportunity for services for older people health and social care teams care, domiciliary care, social care and a practices to feedback and younger disabled delivering services for older independent care better ability to good practice or any adults in Swansea. people. providers manage demand. concerns. Linking in with network to ensure appropriate and consistent linkages are made. Network to inform the review of the single point of access (Intake) for the integrated team 3 INR service ensuring INR Enhanced Service to be Health Board Nov 2016 Safer services Ian Harris attended – – dosing and prescribing commissioned across practices GP practices +/- dependant on through not the Bay cluster are not separated secondary care issuing of agreed separating roles of meeting held during Bay cluster to agree whether services +/- HB Directed monitoring and July 2016 to present Review of INR service to INR service to be cluster based medicines Enhanced Service prescribing in line and discuss the – ensure includes NOACs or provided by the Health Board management teams with MHRA proposed model to GP practices. 4 Education of practice & Develop shared education GP practices, Health Ongoing Staff remain up to Network lead community teams agenda through community Board, Community date continues to secure a network PLTS staff range of speakers
No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date/Current Position RAG Rating 1 Bay cluster to work closely with Local Area Coordinators To agree clear eligibility criteria in order for practices to refer suitable patients To assist in the promotion of Local Area Coordinator projects in relevant practice areas Health Board / Practices / Local Area Coordinators March 2017 Better sign posting to services that can meet patients social needs LACs have attended network meetings to introduce themselves to discuss the project follow up work will include linking to the Early Adopter Pilot. 2 To continue to support the development of integrated health and social care services for older people and younger disabled adults in Swansea. To act as a key stakeholder in informing the ongoing development of integrated health and social care teams delivering services for older people. Linking in with network to ensure appropriate and consistent linkages are made. Network to inform the review of the single point of access (Intake) for the integrated team Social Services, community nursing, third sector, primary care, domiciliary care, independent care providers March 2017 and ongoing More effective, timely and health and social care and a better ability to manage demand. Updates are regularly received at network meetings with opportunity for practices to feedback good practice or any concerns. 3 INR service – ensuring dosing and prescribing are not separated Review of INR service to ensure includes NOACs INR Enhanced Service to be commissioned across practices Bay cluster to agree whether INR service to be cluster based or provided by the Health Board Health Board GP practices +/- secondary care services +/- HB medicines management teams Nov 2016 – dependant on issuing of agreed Directed Enhanced Service Safer services through not separating roles of monitoring and prescribing – in line with MHRA Ian Harris attended the Bay cluster meeting held during July 2016 to present and discuss the proposed model to GP practices. 4 Education of practice & community teams Develop shared education agenda through community network PLTS GP practices, Health Board, Community staff Ongoing Staff remain up to date Network lead continues to secure a range of speakers
Bay%20GP%20Cluster%20Network%20Action%20Plan%202016%20-%2018.01.2017.docx