S42 Integrated Community Teams


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Joint working in community teams has developed across Scotland and across a range of care groups over a number of years. This workshop shares the learning from an award winning integrated team and explore some of the key, common messages for practice. It highlights challenges in developing the workforce, mainstreaming the approach and spreading this to other localities. The team outlines examples of successful outcomes in the context of health and social care integration. Contributed by: Joint Improvement Team & South Lanarkshire Partnership

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S42 Integrated Community Teams

  1. 1. Integrated Community Support Teams (ICST) East Kilbride and Strathaven Lanarkshire
  2. 2. Where did we start from • Stakeholder event – Tentative model • Information sessions with staff • Ongoing development sessions with staff and carers and stakeholders
  3. 3. INTEGRATED COMMUNITY SUPPORT TEAM • ICST uses a township based, whole system approach to support the health and social care needs of older people. The twenty four hour, seven day service allows them to remain in their community setting, for as long as possible.
  4. 4. Integrated Community Support Team LTC Team Leader District Nurses Community Staff Nurse Clinical Support Workers Physiotherapists Occupational Therapists Admin & Clerical Social Care Team Leader Social Workers Homecare Team Leader Homecarers Social Work OTs
  5. 5. Carers 3rd sector support Specialist nurses Specialist AHP’s Community Mental Health Other change fund projects Falls TeamDischarge Hub Rapid Response Community Geriatrician Pharmacy GP
  6. 6. Bases OVERNIGHT ICSTs 1&2 and HOMECARE DISCHARGE HUB in HAIRMYRES HOSPITAL ICST 2 GREENHILLS HEALTH CENTRE ICST 1 HUNTER HEALTH CENTRE GP caseload Population=35,603 3,196>65yr 2,536>75yr 700>85yr GP caseload Population=31,808 3,447>65yr 2,164>75yr 670>85yr Social work and Homecare Civic Centre
  7. 7. PROCESSES • Eligibility criteria • Referral process • Single Point of Access • Documentation • Info sharing – MIDIS and e-care viewer • Equipment • Supporting groups e.g LCG, RAG, Practitioner Group, Lead Professional
  8. 8. SUCCESSES • Motivation levels of existing staff • Commitment to improve the experience of individuals using the service • Continuity of nursing services • Improved practitioner communication • Staff feel they are offering much more for the person • Single point of access
  9. 9. Successes • Commitment from all disciplines and partners • Leadership and a robust consultation process • One nursing team 24/7 with additional co- located Homecare overnight • Joint processes and procedures for Health and Social Work • Greater respect and understanding of roles and responsibilities; this has brought about a blurring of professional boundaries with integrated outcomes for the person/carer
  10. 10. Challenges • Recruitment , new and changes • Accommodation Issues • Responsiveness/ flexibility of agencies • Cultural Change for Staff • Contractual changes for some staff • Size of teams • Agreement of processes within different organisations
  11. 11. Challenges • Changing traditions and cultures • Having one discipline manage multiple professionals • Lack of co-located facility • Negotiating new interagency boundaries • Demonstrating the achievement of the set strategic outcomes for the project against a backdrop of an ever changing political agenda
  12. 12. What do staff say • They did not feel that there was enough representation from them at the planning stage. • Some people found it difficult to adapt to the organic growth nature of the project • They would have liked definite policies and procedures at the beginning • All liked that they helped the project to grow, this was empowering • Communication was much improved and speedier between disciplines • There is now a sense of identity with ICST
  13. 13. What staff say continued • The outcome for the individual and their carers/family is much better • The use of other agencies such as the voluntary sector has improved • The blurring of the professional boundaries continues to develop • Their understanding of each others roles and responsibilities is far greater than before • I.T. has to improve to enhance what is being delivered on the ground • A joint management structure is the way to go