Better, sooner, more convenient health care in Midlands

7 Delivering on health targetsHow we will implement that changeEquity of accessScreening populations who do not traditionally engage with health services.Referrals are organised in a systematic and consistent way that encourages equity of access forfurther specialised procedures.Programmes developed reflect a number of options for service delivery settings and hours in orderto ensure the availability of potential service users.Active Case ManagementMaintaining a pro-active relationship with all identified high-risk patients.Maintaining a pro-active relationship with all diagnosed patients.Programmes regularly and persistently encourage high-risk and diagnosed patients to self-managetheir health.Referrals are organised in a systematic and consistent way that encourages access for furtherinteraction with local service providers when the initial patient event is managed away from the localarea of residence.Road Map for Cardiovascular problemsA personalised directory to help cardiovascular patients navigate through their care and to assistwith the self-management of their condition.Take 10 to add 10An approach to healthier lifestyles that addresses the specific risk factors for chronic disease. A setof resources created for use in general practice, to encourage promotion of simple lifestyle changein consultations with patients. 10 minutes a day, 10 week programmes, 10 people in a group, live 10years longer.Be good to your heartA multi-media resource set aimed at patients with a low level of health literacy. The resource isdesigned to be visual, highly interactive and very user friendly. Focus is on the key health messagesaround cardiovascular, and how to achieve self-management.KPIs100% of the target population receives a cardiovascular risk assessment.All people whose screen results in “at risk” are on an actively managed plan.93