We recognise that people want to remain as independent as possible, for as long as possible and that they want to have care as close to home as they can. Therefore, supporting people to stay out of hospital where possible but also to return to a home setting after a hospital stay as quickly and safely as we can is important.

Our aim is to transform and build out-of-hospital and community services to deliver a ‘home first’ philosophy. The plan describes how we will do this by:

  • investing in community services to respond quickly when people are in need and to prevent hospital attendances
  • recognising and preventing falls as these are a major contributor to hospital stays
  • developing more capacity for people to receive care in a home setting through remote technology and virtual wards
  • supporting people in their end-of-life choices and ensure there is support and care there for people to die in a place of choice with dignity
  • delivering the ambitions of the Black Country Integrated Care Board (ICB) Dementia Strategy ensuring it aligns to the Palliative and End of Life Strategy
  • creating a recognised tool to assess and direct individuals to the most appropriate community service across the ICB, providing care closer to home
  • implementing the National Chief Nurse Officer’s Strategy.

Outcomes to be achieved

  • Increased independence.
  • Care Closer to Home.
  • Equity of services.
  • Reducing time spent in hospital.
  • Reduced readmissions to hospital.

  • Increased efficiency/productivity by improved utilisation/standardisation of out of hospital pathways.
  • More efficient use of resources (workforce, equipment and estates).

  • Collaboration/joint working with wider system partners e.g. Local Authorities, third sector.
  • Greater integration of pathways/services.
  • Improved access and health outcomes.
  • Reduction in health inequalities.

Work Programme

Programme To be delivered

Single Triage Model for Urgent Community Response (UCR) Service

To deliver a single integrated model that achieves consistency, removes duplication and embeds collaborative working.

2023/24 to 2024/25

Recognised Falls Model in the Black Country

To implement a consistent standardised falls management approach across the system, minimising risk to patients and reducing the demand for urgent and emergency care services.

2023/24 to 2024/25

Continued Development of Remote Monitoring and Virtual Wards

The expansion of monitoring in care and at home and virtual wards offer across the Black Country, working in partnership with Local Authorities to support roll out of tech enabled schemes.

2023/24 to 2026/27

Effective Discharge from Hospitals to create flow

We will discharge to the most appropriate setting in a timely/ effective way to support the best patient outcomes, ensuring flow for patients requiring acute care, working with partners and neighbouring systems.

2023/24 to 2024/25

Palliative and End of Life Care

Implementation of the Palliative and End of Life Care Strategy encompassing adults, children and young people.

2023/24 to 2025/26

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