WSIC - Kingsbury and Willesden

Description

To ensure continuity of the service, a short term contract has been awarded to K&W Healthcare Limited whilst undergoing a procurement exercise for the service. Market Engagement has been undertaken in advance. NWL CCG currently has a Whole System Integrated Care/Integrated Care Partnership (WSIC/ICP) service in Brent, which provides a multi-layer level of investment across Primary Care to deliver an integrated model of working between healthcare professionals, patient and carers in the management of long term conditions. This model puts GP-patient relationship at the centre and uses the GP register as a source for population health management. The WSIC model provides functions and services designed to support integrated and coordinated care for adults with complex long term conditions. The key service requirements are: •Risk stratification and proactive case finding from Population Health management via the WISC dashboard and GP registered lists •Proactive care planning - Enhanced care planning, •Multidisciplinary case management - enhanced mainstream care and intensive case management for a subset of patients. •Support to self-care: Support tailoring of care plans and care delivery •Weekly Complex Patient Management Groups (CPMG) - case management meetings hosted by each Network's Core Team •Weekly Multidisciplinary Group meetings - hosted by and within each GP Network with the participation of individual GP practices, CPMG members, integrated Care Management team and specialists as required •Enhanced Care Plan review - regular review and review in response to trigger events by the patient's own GP, with onward referral and case management as required.