Health services

Tender description

NHS South East Staffordshire and Seisdon Peninsula, NHS Cannock Chase and NHS Stafford and Surrounds CCGs wish to commission the delivery, coordination and operational management of a staying well pathway extended pilot. This service will be offered on the basis of direct referral of patients with mild to moderate frailty registered with a participating practice the above CCGs. The aims and objectives of the staying well services extended pilot project is to deliver a safe and effective pathway and a multi-disciplinary team (MDT) based service which enables service users to avoid hospital admissions. The overarching aims, and objectives are to: — enhance the patient pathway by effectively assessing, referring and managing patients within the most appropriate setting, — provide fast, timely access to assessment, treatment and care, — prevent avoidable hospital attendance and admission, — contribute appropriate data to monitor impact of the service. The extended pilot will develop and mobilise services which are focused in the South of Staffordshire i.e. Cannock Chase CCG, South East Staffordshire and Seisdon Peninsula CCG and Stafford and Surrounds CCG areas. The staying well pilot provides a pathway which starts with active case finding by GP's in Primary Care, referral to an elderly care facilitator holistic assessment in patient's homes and, if appropriate, referral to a staying well hub where the service will provide a range of clinical skills and access to acute and community services .and follow up. Partner agencies will have a clear memorandum of understanding taking ownership of the joint approach and putting the patients' care at the centre. The service will make use of the emergent integrated record as a tool. The CCGs are proposing to award a new contract to an existing community services provider. The staying well service is a 24-month pilot, to allow the CCGs time to complete a comprehensive evaluation of the staying well approach across a number of different geographical areas and utilising different models.