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Our Approach to Delivering Community Health Services

Care Closer to Home is transforming the way different parts of the local health system work together so we can be more responsive to our local population's needs.  This means new developments like:

The Community Gateway

Our approach to patient-centred care starts with the Community Gateway. This provides a single access point and seamless experience for patients and carers/families, referring clinicians and our stakeholders. The Gateway will be accessible via a single widely-promoted phone number, email and on-line facility going live from April 2016.  

Single Assessment 

Single assessment is designed to ensure patients’ overall circumstances are better considered.  A single assessment process will be used to identify patients' holistic needs including medical issues, mental health and dementia, functional capacity, social issues, carer status and environmental circumstances such as housing. 


Care planning and navigation

All patients accessing Care Closer to Home services will be assigned a named Care Co-ordinator as their first point of contact. This role will co-ordinate a single assessment and patient-owned care plan, as well as supporting the patient and carer to determine their own goalsAll key staff will be trained in care planning to support this process, and help to monitor progress, review and modify with the patient and their carer/family. This will ultimately support the patient and carer to transit to discharge and self-management.


Empowering service-users and carers

Healthcare works best when patients and carers are in control and professionals tailor our input to their needs, care plans and capabilities. This means collaborative decision making between the patient, carer and their care co-ordinator to set goals, review progress and agree actions. To support patients on the journey to self-management, we need an empowerment approach to care, training our staff in health coaching and goal centred personal planning.


Shared care records 

Underpinning all of this is a shared care record.  We aim to have a plan for sharing records with patients and support staff ready by 2017.