05/03/2025
We are delighted to announce that last week we won a South West Integrated Personalised Care Award for 'Living in a Digital Age'. You can read more about the work below but it recognises the digital tools we use to deliver personalised care through our wonderful Living Well Team (Frailty Nurses, Occupational Therapist, Social Prescribers and Care Coordinators). This was truly a team award and we would like to take this opportunity to recognise the magnificent work of this team!
This Primary Care Network are developing their Integrated Neighbourhood Team to enhance patient care through linking proactive & personalised Care in a way that impressed the judges. These initiatives are designed to build capacity, improve patient experience, and introduce innovative tools that support a more holistic approach to healthcare.
At the heart of this work is the Proactive Whiteboard designed to identify and risk-profile vulnerable patients, ensuring they receive timely, proactive support. By leveraging data and clinical insights, the surgery can intervene early, preventing health deterioration and reducing the need for crisis care.
Understanding that patient-centred care goes beyond medical treatment, the team have also co-designed the "What Matters to Me" folder and Personalised Care & Support Plans – Me at My Best. These resources empower patients to articulate their priorities, goals, and support needs, fostering a truly personalised approach to their healthcare journey.
Recognising the importance of collaboration, the surgery have worked with partners to co-develop their Integrated Neighbourhood Team—a multi-agency approach that connects healthcare professionals, social care providers, and community organisations. By "joining up the dots," this initiative ensures that patients receive coordinated, seamless support that addresses both their medical and social needs.
Community engagement has also been a key focus, with the surgery establishing place-based meaningful activities tailored to the needs of registered patients. These initiatives encourage social connections, mental well-being, and proactive self-care, reinforcing the belief that good health extends beyond clinical settings. By embracing supported self-management tools enabling individuals to take an active role in their health and well-being and providing patients with the right tools and resources, the surgery is fostering independence, confidence, and improved health outcomes.
This work exemplifies promising practice linking better understanding of data with a personalised care model to improve outcomes for people in developing Integrated Neighbourhood teams.
Churchdown Surgery Brockworth Surgery Longlevens Surgery Hucclecote Surgery The Alney Practice NHS Gloucestershire