Live Well Service in Milton Keynes

Tender description

Employment of a frequent user lead in Milton Keynes aims to deliver the following outcomes: • Effectively manage, coordinate and sign post High Intensity Users of the local ambulance service and A & E within the CCG footprint. • Reduce the activity High Intensity Users have on GP practices • Establish, utilise and coordinate multi-agency and existing professional services to negotiate an adequate reduction in 999 calls including connection with local communities, statutory and non-statutory agengies as required. • Co-ordinate the fortnightly HIU MDT Meetings • Demonstrate a reduced workload on unscheduled care services and the wider health economy resulting from reduced 999 calls, which otherwise would have attended A&E, result in an admission. • Safely manage and coordinate the chaotic and demanding nature of the patient group through the use of multi-agency support and the volunteer sector. • Provide fertile commissioning intelligence across all providers and in doing so, lower the stigma associated with High Intensity Users. • Coordinate a replicable service which can be integrated and managed over the longer term across other providers. The objectives of the scheme are to:- Measurable: • Identify those at greatest risk of 999 calls, A&E attendance and non-elective admissions. • Proactively manage a rolling cohort of High Intensity Users using a truly personalised approach. • To coordinate, sign post and oversee other identified High Intensity Users • To coordinate the 2 weekly HIU MDT meetings • To provide training and support to other providers to ensure patients are empowered to take ownership of their health and well-being whilst decreasing their dependency upon unscheduled care services. • Reducing 999 calls • Reducing A&E attendances and avoidable emergency admissions More difficult to measure but essential: • Forming robust network of community health, social care, mental health and police to manage patients, creating true integrated working. • Providing a service driven by quality with positive human outcomes observed. • Act as a conduit to negotiate and de-escalate issues before a crisis occurs; a situation which has historically led to a destabilisation of their condition and resulting in a 999 call. • Improving communication and partnership working between those involved in patient care 24/7. • Assist other providers to identify patterns and 'causal factors' which trigger relapse behaviours in former High Intensity Users in order to shape future commissioning of service and/or demand/capacity planning • Empower patients to self-manage.to enable discharge and to switch them from negative to positive contributors of society. • Drive equality and patient voice.