High Intensity users Clause Samples

High Intensity users. High intensity user schemes meet NW London requirements for consistency, with care plans developed on CMC and enacted across the system • Care plans for high intensity users are shared across local primary, community, London ambulance and acute organisations on Co-ordinate My Care (CMC), through NW London data sharing agreements and patient consent • Local systems demonstrate the success of their HIU schemes in reducing hospital attendances, in line with NW London requirements. • This Primary care facing and is working with high intensity users as identified by LAS and ED attendances who have attended more than 6 times in 6 months • It is based in the community, working with GP’s, MCMW case managers and other community services via MDT meetings and development of care plans on CMC. • The initial target group for the programme (50 patients) has annual ED attendances of between 15 and 90 and include patients who have complex profiles of multiple physical, mental and social conditions • CMC care plans are being initiated for patient’s identified as high intensity users and enacted across the system. • Care plans for high intensity users are shared across local primary, community, London ambulance voluntary sector and acute organisations on Co-ordinate My Care (CMC), through NW London data sharing agreements and patient consent • Hounslow have set a frequent attenders MDT where patients flagging as HIU are discussed and care plans and actions are initiated. These actions are fed back to primary care to discuss with patients. Outcomes are monitored on a monthly basis. • Approximately 7 patients are reviewed per month. • Links have been developed with Imperial to ensure a consistent approach for patients that present to more than one site.