The film 'Sam's Story' explains our joint vision of integration.
The film highlights the issues of seeing so many health care professionals, in some cases repeatedly, and how processes and duplication can slow or prevent Sam returning home from hospital. On returning home he finds a lack of co-ordination between the local GP and social care team, which often means the support and care he needs is miscommunicated between services.
But what if health care services were more joined up? Instead of teams working independently, let's give one of Sam's carers overall responsibility for co-ordinating his care. For example the District Nurse would meet with Sam and discuss his needs and wishes. Sam chooses to remain at home and receive the support and care he needs where he loves most.
The District Nurse would then meet with the GP and social worker to develop a care plan that they can all access in one place. If Sam should have a crisis or feel unwell, he calls the nurse rather than an ambulance which avoids being admitted to hospital. However, if he is admitted to hospital, the care plan is discussed by the team and updated and he is able to return home faster.
Our shared vision of what good integrated care could look like in Powys puts the citizen at the centre of every decision made in respect of their care and support, and gives them a voice and control over what they need most.