PHM : Making the Concept a Reality
The MDT approach with wider engagement of Social Prescribers, Community Services, Community Heart Failure Team. We are a small PCN with a limited workforce nearly all with competing interests and largely very siloed working within the PCN.
We created a digital platform specifically for the project that was not required due to limited capabilities of the cohort selected.
Identifying hidden problems such as low level mental health, social isolation due to covid and how we engaged the selected cohort and the difficulties faced.
- Working on this projected has highlighted the benefits of having a team dedicated to the same cause.
- The importance of drawing on expertise from outside the core PCN team like the HF Nurse and Digital expert.
- Original Data started out with 116 but ended with 37 as due to challenges with coding from primary and secondary care.