Common use of Care Model Implementation Clause in Contracts

Care Model Implementation. Health and wellbeing teams referred to in the Operational Plan will be providing a range of functions details of which are below: • Encourage self-care, healthy lifestyles and maintain independence • Help to grow community assets/develop resilience; • Assessment, support planning and professional social work support; • Provide rehabilitation; • Provide nursing care; • Integrated medical management of people with complex co-morbidities; • Reactive care coordination of people with deteriorating complex health issues and frail elderly; • Continue to imbed and mainstream Learning Disabilities and working with the voluntary sector to support the delivery of this • Proactive care co-ordination of people with complex needs and frail elderly; • Proactive integrated long term conditions support; • High quality discharge support from hospital to home, integrated planning and seamless handover of care; • Development of a fully integrated out of hospital care system for Torbay and South Devon, providing onward care which is focused on improving independence. • Provide falls prevention services; • Provide palliative care as part of end of life care pathway. In addition to the Trust’s internal governance structures the impact of these changes on community based care roll-out will be monitored and assured through the ASCPB in respect of the community activity

Care Model Implementation. Health and wellbeing teams referred to in the Operational Plan will be providing a range of functions details of which are below: •  Encourage self-care, healthy lifestyles and maintain independence •  Help to grow community assets/develop resilience; •  Assessment, support planning and professional social work support; •  Provide rehabilitation; •  Provide nursing care; •  Integrated medical management of people with complex co-morbidities; •  Reactive care coordination of people with deteriorating complex health issues and frail elderly; •  Continue to imbed and mainstream Learning Disabilities and working with the voluntary sector to support the delivery of this •  Proactive care co-ordination of people with complex needs and frail elderly; •  Proactive integrated long term conditions support; •  High quality discharge support from hospital to home, integrated planning and seamless handover of care; •  Development of a fully integrated out of hospital care system for Torbay and South Devon, providing onward care which is focused on improving independence. •  Provide falls prevention services; •  Provide palliative care as part of end of life care pathway. In addition to the Trust’s internal governance structures the impact of these changes on community based care roll-out will be monitored and assured through the ASCPB in respect of the community activity