How will the model work
Under the new model a patient, for example with frailty & long-term conditions, registered with a GP in Dudley, will have their care overseen by a multi-disciplinary team in the community.
This will ensure a more rounded approach towards care that better meets all of the patient’s medical and social needs at one time in one place.
The links that we are developing with the voluntary sector also help to ensure that they have access to support and care from their local community.
Their long term condition will be managed through a new framework which includes evidence based outcome measures and personal goals. They will be supported to manage their own condition and have care coordinated by the GP.
If a patient needs help urgently there is a community rapid response service and urgent care centre in Dudley. These provide co-ordinated points of access for urgent support which are clearer and easier to access.
As a result of the health and care system working better together in this way, patients are not only receiving the coordinated support necessary for their health needs but they are also linking to the wider network of care and social interaction in their community to help them to live more independently for longer.