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2: Integrated Neighbourhood Care Teams

Strengthen the contribution of neighbourhood care teams to improving care coordination for people with multiple long term conditions. Provide better, local and faster access to services for patients with multiple long term conditions at an earlier point in the care journey to activate pro active care. The cohort of people outlined above requires a careful holistic assessment based on a sociomedical care model. Commissioning of care where patient centric decision making is crucial. Many people will have social, psychological, economic and environmental factors that cause additional complexities to their needs. Where possible, service delivery should be re-designed to support people with multiple morbidities. This type of care delivery requires a fully integrated response across health, social care, housing, employment, benefits and voluntary sectors.


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