East Kent
South East
Delivery of Health & Care in Folkestone has been transforming for some time and there were firm foundations upon which to accelerate aNeighbourhood approach. The focus of the East Kent Neighbourhood Pioneer programme (NNHIP) has multi-faceted with there being an immediate focus on the highest risk patients from an organisational activity perspective as well as those patients what locally are keen as the main population focus.
Using multiple data sources including the Johns Hopkins PNG scores, Complex Geriatric Assessments, Structured Medication Reviews and advanced care planning the 3 PCNs identified the immediate Complex multi-morbidity and frail cohorts (PNG 10 & 11) that included Care home and EOL status.
We have introduced new streamlined and co-located working between General Practice, community providers and system partners and built upon existing MDT structures to remove some of the handoffs and standardise both process and roles. This has brought teams together to streamline the day-to-day ways of working between them, understand needs, improve navigation and reduce unnecessary workload on staff. To manage the broader needs of these group social care and proactive MDTs are in place to plan more broadly than the health intervention
QI is at the heart of everything, and it has driven real changes on the ground resulting not just in the co-location of nursing & navigation staff but shared teams communication channels, single DOS & SPOA, consolidation of roles. There currently are 13 PDSA cycles in play.
Working with the ICB the PCN have developed a single and multi-neighbourhood model to manage the care of the PNG 10 & 11 cohort both locally and when necessary be able to escalate to a wider team to intervene and prevent further escalation. Although in the very early stages this is a huge achievement and the ICB plans to begin to roll out contracting arrangements in April 2026.
East Kent have been keen to remain focus on the longer term achievement of the “left shift” strategy so have built out their approached through CYP MDTs, Proactive focus on multi-morbidities, elective outpatient (including Oncology) as well as building a business case for investment in the Community Health and Wellbeing Workers.
Our broader focus in the immediate months is to share the learning across Kent & Medway and begin to formalise the workforce structures to enable a systematic rollout of neighbourhood approaches.
Series of workshops have been run and continue to be in each PCN area to bring in the community patient and VCSE voice More recently in the Marsh PCN linking up via a community questionnaire that received over 600 responses which was used alongside activity data to shape and co-develop future solutions with the community and partners.
Delivery of Health & Care in Folkestone has been transforming for some time and there were firm foundations upon which to accelerate aNeighbourhood approach. The focus of the East Kent Neighbourhood Pioneer programme (NNHIP) has multi-faceted with there being an immediate focus on the highest risk patients from an organisational activity perspective as well as those patients what locally are keen as the main population focus.
Using multiple data sources including the Johns Hopkins PNG scores, Complex Geriatric Assessments, Structured Medication Reviews and advanced care planning the 3 PCNs identified the immediate Complex multi-morbidity and frail cohorts (PNG 10 & 11) that included Care home and EOL status.
We have introduced new streamlined and co-located working between General Practice, community providers and system partners and built upon existing MDT structures to remove some of the handoffs and standardise both process and roles. This has brought teams together to streamline the day-to-day ways of working between them, understand needs, improve navigation and reduce unnecessary workload on staff. To manage the broader needs of these group social care and proactive MDTs are in place to plan more broadly than the health intervention
QI is at the heart of everything, and it has driven real changes on the ground resulting not just in the co-location of nursing & navigation staff but shared teams communication channels, single DOS & SPOA, consolidation of roles. There currently are 13 PDSA cycles in play.
Working with the ICB the PCN have developed a single and multi-neighbourhood model to manage the care of the PNG 10 & 11 cohort both locally and when necessary be able to escalate to a wider team to intervene and prevent further escalation. Although in the very early stages this is a huge achievement and the ICB plans to begin to roll out contracting arrangements in April 2026.
East Kent have been keen to remain focus on the longer term achievement of the “left shift” strategy so have built out their approached through CYP MDTs, Proactive focus on multi-morbidities, elective outpatient (including Oncology) as well as building a business case for investment in the Community Health and Wellbeing Workers.
Our broader focus in the immediate months is to share the learning across Kent & Medway and begin to formalise the workforce structures to enable a systematic rollout of neighbourhood approaches.
Series of workshops have been run and continue to be in each PCN area to bring in the community patient and VCSE voice More recently in the Marsh PCN linking up via a community questionnaire that received over 600 responses which was used alongside activity data to shape and co-develop future solutions with the community and partners.
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