South TynesideIntegrated Community Teams

3rd March 2015

South Tyneside - Who are weOver reliance on

hospital services Population 150,000

28 GP Practices

1 Foundation Trust

1 Local Authority

Growing elderly

population

Clinical

Variation

Fragmented

Services

Risk

taking

behaviour

Poor

Mental

Health

Integration Principles

We will impose a person

perspective throughout our

work

We will manage the organisational consequences of

being person-centred

Our staff will not automatically

reach for traditional solutions

We will develop our staff jointly, not separately

“I can promote my own health and wellbeing by planning my care & support with people who work together to understand

me and my carers, allow me control and bring together services to achieve the outcomes important to me”

Our vision for integration

Aim of Integrated Community Teams

The vision is to develop existing community services into integrated locality teams providing

joined up health and social care support to residents of South Tyneside

To have services delivered slickly around the needs of the patient

Current provision

Many different teams, individuals and providers delivering a range of health & social care tasks

Mental health Palliative care

Diagnostics

Therapy/Equipment

Assessment

LTC Management

Social and personal care

Medication

Welfare rights

Nursing care

Dietetics

Moving and handling

Complex wound management

SALT

Housing

Acute Care team

Current provision

• Workforce capacity;

– 150 WTE Community Nurses

– 11 Home Care Providers

– 60 WTE Social Care Staff

– 28 GP Practices

• Hand offs, fragmentation, duplication, limited information sharing

• Opportunity to improve patient experience

Patient & Partner

GP

Cons. Memory

Cons. Geriatrician

DN

CM

ICTACT

SW

Care Provider

Age UK

Alzheimer's Society

What is integration?

• ADD SAMS STORY

So what are we doing about this?• We have a model – eventually!

• Prototyped it for 3 months involving 3 GP practice populations in Hebburn

• Scaling up to 9 practices in Jarrow and Hebburn in March

• We are continually developing the model, bringing in more services over time and increasing the services provided by the team

• We are committed to action learning and developing the model together!

West hubHebburn/Jarrow

East hubSouth Shields

No. of delivery

teams TBC

South hubWhitburn/

Cleadon/Boldon

Prototype

Phased Implementation

Delivery Team 1

Hebburn

Delivery Team 2 Jarrow

Practices (See below)

Practices

Delivery Team 1

The Park

Ellison View

The Glen

No. of Practices TBC

No. of Practices TBC

No. of delivery

teams TBC

In place from

17th

November

2014

Snowball approach to implementation

DN

CM

SW

Mental Health

Home Care Providers

Palliative Care

Children's services

Patient & Partner

GP

Cons. Memory

Cons. Geriatrician

ICT

ACT

Care Provider

Age UK

Alzheimer's Society

Patient & partner now have just 2 main points of contact as the Care Coordinator delivers, manages and liaises with the community services, and the GP role is strengthened through these streamlined relationships

Integrated Team – Care Coordinator

Social Worker

Social Navigator

District Nurse

GP

District Nurse

Community Matron

Patient Stories: Community Matron

Day 1- 17th November

• Prevent duplication of services!

• Information sharing

• Clinical handover

• Practicalities

– Duty board

• Blurring of the roles

Pre Go-Live Guide• Pre –meet and greet• Case load identification, transfer, allocation and

identification of care coordinator• Access to the building!

– Swipe cards

• Access to IT – Access to STFT log on– Hardware– Software (SWIFT)– Printers

• Office set up– Integrated seating– Duty Board

Post Go-Live Guide

• Information sharing processes remains ongoing

• Ways of working with practices– Integrated approach to MDTs

• Establish regular structured hub meeting

• Captured lessons learnt

• Develop Skill matrix

• Consider OD offer (staff led!)

Patient storiesDistrict Nurse

Pre integration Patient story

Not integrated!Fragmented care & communicationTime delays in referral processIndirect referrals

38 year old ladyMultiple health and social care needs

Post integration Patient story

Direct referral processJoined up serviceJoint visits/reduction in visits Information sharingBlurring of roles/crossing organisational boundariesOne stop shop for patientsImproved patient outcomes

81 year old gentlemanMultiple LTCs and social care needs

Patient stories

Social workerPre integration Patient story

Unable to accept direct referralsReferrals going outside of the ICTInformation gathering

82 year old gentlemanDementia

Post integration Patient story

Information sharingAble to accept internal referralsCompletion of joint visits

80 year old gentlemanLung CA

Impact of integrated teams

• The impact of the prototype team is being measured in the following key areas:

Service user and carer experience

GP and staff satisfaction

Reliance on hospital and residential services

Team operational metrics (e.g. no and types of visits, inter-team referrals etc)

Our journey

• NHSIQ support

Workshop facilitation: getting our partners working together

Support to generate whole system commitment to the change process

Practical tools and techniques

Guided the local team through the journey from inception to implementation through a bottom-up approach

• The highs

Genuine partnership working

Focus on improving services for patients

Enthusiasm from front line delivery teams

GP practices have wanted small local teams aligned to them for years

Bottom-up approach from all disciplines and skill mixes

Voluntary Sector part of core teams

Going live!

Our journey

• The challenges

Significant work between workshops

Large resource commitment

Overcoming organisational boundaries

Small operational issues having a big impact

1. Commit operational and managerial time to the change process from all organisations – don’t underestimate this

2. Understand the power of actual patient voices and examples of the care they are experiencing pre and post change

3. Make sure that teams and GP practices have funded time out to learn, input and ultimately own the model

Our journey Reflections and Top Tips

4. Importance of going through the journey not jumping to the conclusion – support from NHSIQ invaluable

5. Don’t let IT and system incompatibility get in the way. Think of practical ways to work round it. The IT can catch up over time and it’s not a deal breaker

Final message from the team…

Remember why we’re doing this:

– It’s better for the patient!

– It’s better for the professionals!

– Its just better!!

• We have one Team of professionals meeting the needs of a practice population

• Embrace Change

• All Issues have Solutions !