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Neighbourhood Development - Coggle Diagram
Neighbourhood Development
Primary Care
General Practice and Primary Care Networks
Neighbourhood planning and coordination
GP access and continuity of care
Alignment with Integrated Neighbourhood Teams
Proactive Care and Priority Cohorts
Care home residents and housebound people
Frailty and multiple long-term conditions
End-of-life care
Care Coordination
Named care coordinators
Multidisciplinary case discussions
Personalised care and support plans
Pharmacy and Medicines Optimisation
Pharmacists and pharmacy technicians within teams
Structured medication reviews
Medicines safety and prescribing optimisation
Community pharmacy pathways
Wider Primary Care Partners
Dentistry: prevention and early identification
Optometry: proposed monitoring and early detection roles
Roles requiring further development in the draft
Digital and Population Health Tools
Risk stratification and proactive identification
Shared care records
Digital referrals and NHS App acces
Secondary Care
Hospital–Community Interface
Specialist input to neighbourhood teams
Communication across services
Shared care pathways
Planned Care Transformation
Outpatient redesign
Coordinated patient journeys
Shift from hospital to community
Discharge and Transfers of Care
Timely discharge
Discharge medicines reconciliation
Safe transfer of prescribing responsibility
Community follow-up
Linked Community and Acute Interface Services
Virtual wards and remote monitoring
Urgent Community Response
Intermediate care and rehabilitation
Diagnostics and Same Day Emergency Care
Digital Integration
Interoperable patient records
Electronic prescribing
Shared information across care settings
Preventing deterioration
Reducing admissions and readmissions
Supporting recovery and independence
Mental Health Services
Integration into Neighbourhood Teams
Joint working with primary and community care
Mental health professionals within multidisciplinary teams
Identification and Assessment
Mental health needs within priority cohorts
Holistic assessment
Mental health-specific assessment tools
Personalised Support
Coordinated care and support planning
Shared decision-making
Support shaped around individual goals
Access and Referral
“No wrong door” access
Navigation to appropriate services
Links with wider specialist support
Partnerships and Medicines Support
Voluntary sector and social care connections
Access to mental health pharmacy expertise
Shared records and multidisciplinary decision-making
Public Health
Population Health Intelligence
Joint Strategic Needs Assessments
Linked health and care data
Population segmentation and risk stratification
Prevention and Early Intervention
Vaccination and screening uptake
Smoking cessation
Obesity and diabetes prevention
Prevention of multimorbidity
Health Inequalities
Deprivation and unequal outcomes
Rural and coastal access barriers
Targeted outreach and equitable access
Digital exclusion
Wider Determinants of Health
Housing
Employment
Social isolation
Community resources and resilience
Local Priorities and Strategy
Neighbourhood population needs
Population health strategy
Health and Wellbeing Board alignment
Evaluation and Improvement
Health and wellbeing outcomes
Healthy life expectancy and independence
Prevention impact
Continuous learning and quality improvement