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​Developing care coordination for people with long term conditions

joining up.jpg

Local care networks (LCNs) bring together a range of health care professionals working together as a team in the community including doctors, nurses, social workers, housing support workers, home care workers and therapists who work with a patient to achieve the goals that are important to them in a clear jointly agreed way. 

Local care networks across Lambeth and Southwark are prioritising the delivery of co-ordinated care to people  with three or more long term conditions. The new approach to care coordination was launched in October 2017.   Healthwatch Southwark has talked to patients about their views as part of the evaluation of this pilot in January and February 2018 and you can read their report here.   

In September 2018 we ran two workshops - one in north Southwark and one in south Southwark  - to explore with local people what they like doing in their local areas or neighbourhoods, what more they would like to do and what support they need including from their health and care workers.  This will help inform the approach to developing neighbourhood networks in Southwark.  You can read the report of the workshops here.    

We talked to a lot of people living with long term conditions to help us developed our approach.  You can read a summary  of the key issues people find important here.  You can listen to the experience of Southwark patients, which helped inform the development of our approach to joining up care for people with multiple long term conditions:


How we involved local patients

We engaged with local people with three or more long terms conditions as we developed the new approach:

  1. Developing patient films about what it is like to live with multiple long term conditions  which you can see on our YouTube site 
  2. Collecting patient stories working with Healthwatch Southwark and Revealing Reality.  
  3. Workshop in January 2017 to look at care planning and explore what's important in people's lives
  4. Workshops in July and August 2017 to develop letters and care plan and how we need to approach person centred care planning conversations 
  5. Workshop in September 2017 as part of the launch
  6. Workshop in March 2018 as part of the evaluation of the pilot - you can see the presentation here and watch the film below, in which people talk about what is important for them in joining up care: 

We produced a report for the LCNs. You can read the report of the engagement here

Patient experience to inform the working groups 

Four working groups were established to develop the work plan and test ideas:

  1. Care planning - read patient stories and experience here
  2. Multi-disciplinary team working - read patient stories and experience here
  3. Named professional - read patient stories and experience here
  4. Self-management  - read patient stories and experience here

You can read the final report from Revealing Reality bringing together all the themes from the patient stories here.

expand Text : Engagement presentations ‎(4)
expand Text : Engagement reports ‎(3)
expand Text : Revealing Reality reports ‎(5)