Working Together, a partnership programme that coordinates care for individuals with complex or multiple needs, started in Leighton Buzzard and is now also supporting people in Dunstable.
Its aim is to put processes in place to identify what further help people need – whether it be from physical health, social care of mental health support - and then connect relevant services with each other and, most importantly, with people.
The programme helps people of all ages stay healthier by putting multi-agency support in place that can prevent the need for hospital admissions.
It also removes the need for people and carers to identify and contact different providers and services on their own, a process which can prove time-consuming, complicated and frustrating.
People who might benefit from wider support are identified by health or social care professionals, and from other agencies who then share details once consent is gained with the Working Together multi-disciplinary team (MDT) to discuss an appropriate care approach and devise a care package.
Working Together is led by Bedfordshire Community Health Services (BCHS) and Central Bedfordshire Council (CBC). It also involves close working with a range of partners across health providers, social care and the voluntary sector.
“Ensuring everyone is connected – from NHS and social care services through to voluntary and social enterprise partners – is vital to providing the right care for people’s individual needs,” said Working Together clinical lead Helen Mills, from BCHS.
“The biggest things we have learnt are the huge importance of speaking to people, understanding their needs and then good communication with services and organisations across Central Bedfordshire. Information is now documented on electronic systems and everyone is in the loop.”