West London integration model – My Care My Way (MCMW): West London CCG


West London integration model – My Care My Way (MCMW)

West London CCG


Attain supported the West London CCG, in 2015 to develop a pioneering whole systems approach for how care would be delivered for its older adult population, called My Care My Way (MCMW)​.

This involved;

Supporting the CCG through co-designing and delivering the model of care and implementing transformational change with patients, carers, providers, commissioners & clinicians.

What we did

Our support has involved:

  • Building an understanding and shared vision amongst providers about the roles they play in the system and the opportunities for transformation
  • Designing the model of care and community hubs with providers, and aligning with wider services in the system
  • Supporting the business case for investment through the governance of the CCG and providers
  • Designing the programme management and governance
  • Designing a new workforce model – with new roles, including case managers and Health & Social Care Assistants (HSCAs)

Our impact

  • Published evaluation findings in 2018, two years on from commencement of services, show Attain enabled the following impacts to be achieved for the system:
  • patients, carers and GPs speak highly of the service and morale amongst our new Case Managers and Health & Social Care Assistants is high.
  • MCMW reduced non-elective inpatient costs, elective inpatient costs and A&E costs.
  • MCMW has increased Patient Activation Measure (PAM) scores by 2 points, an amount the licensor of PAM says correlates to a 4% decrease in hospitalization and 4% increase in medication adherence in the US health system.

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