Live Well Service in Milton Keynes

Employment of a frequent user lead in Milton Keynes aims to deliver the following outcomes:

• Effectively manage, coordinate and sign post High Intensity Users of the local ambulance service and A & E within the CCG footprint.

• Reduce the activity High Intensity Users have on GP practices

• Establish, utilise and coordinate multi-agency and existing professional services to negotiate an adequate reduction in 999 calls including connection with local communities, statutory and non-statutory agengies as required.

• Co-ordinate the fortnightly HIU MDT Meetings

• Demonstrate a reduced workload on unscheduled care services and the wider health economy resulting from reduced 999 calls, which otherwise would have attended A&E, result in an admission.

• Safely manage and coordinate the chaotic and demanding nature of the patient group through the use of multi-agency support and the volunteer sector.

• Provide fertile commissioning intelligence across all providers and in doing so, lower the stigma associated with High Intensity Users.

• Coordinate a replicable service which can be integrated and managed over the longer term across other providers.

The objectives of the scheme are to:-

Measurable:

• Identify those at greatest risk of 999 calls, A&E attendance and non-elective admissions.

• Proactively manage a rolling cohort of High Intensity Users using a truly personalised approach.

• To coordinate, sign post and oversee other identified High Intensity Users

• To coordinate the 2 weekly HIU MDT meetings

• To provide training and support to other providers to ensure patients are empowered to take ownership of their health and well-being whilst decreasing their dependency upon unscheduled care services.

• Reducing 999 calls

• Reducing A&E attendances and avoidable emergency admissions

More difficult to measure but essential:

• Forming robust network of community health, social care, mental health and police to manage patients, creating true integrated working.

• Providing a service driven by quality with positive human outcomes observed.

• Act as a conduit to negotiate and de-escalate issues before a crisis occurs; a situation which has historically led to a destabilisation of their condition and resulting in a 999 call.

• Improving communication and partnership working between those involved in patient care 24/7.

• Assist other providers to identify patterns and 'causal factors' which trigger relapse behaviours in former High Intensity Users in order to shape future commissioning of service and/or demand/capacity planning

• Empower patients to self-manage.to enable discharge and to switch them from negative to positive contributors of society.

• Drive equality and patient voice.