South Tyneside Partnership on integrated community teams. Slides from the impact and celebration event held in Leeds on 3 March 2015.

1. South Tyneside
Integrated Community Teams
3rd March 2015

3. South Tyneside - Who are we
Over 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

4. 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

5. 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

6. To have services delivered slickly
around the needs of the patient

7. 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

8. 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

9. Patient &
Partner
GP
Cons.
Memory
Cons.
Geriatrician
DN
CM
ICTACT
SW
Care
Provider
Age UK
Alzheimer's
Society

10. What is integration?
• ADD SAMS STORY

11. 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!

12. West hub
Hebburn/Jarrow
East hub
South Shields
No. of
delivery
teams TBC
South hub
Whitburn/
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

13. Snowball approach to implementation
DN
CM
SW
Mental Health
Home Care Providers
Palliative Care
Children's services

14. 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

15. Social
Worker
Social
Navigator
District
Nurse
GP
District
Nurse
Community
Matron

16. Patient Stories: Community Matron

17. Day 1- 17th November
• Prevent duplication of services!
• Information sharing
• Clinical handover
• Practicalities
– Duty board
• Blurring of the roles

18. 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

19. 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!)

20. Patient stories
District Nurse
Pre integration Patient story
Not integrated!
Fragmented care & communication
Time delays in referral process
Indirect referrals
38 year old lady
Multiple health and social care
needs
Post integration Patient story
Direct referral process
Joined up service
Joint visits/reduction in visits
Information sharing
Blurring of roles/crossing
organisational boundaries
One stop shop for patients
Improved patient outcomes
81 year old gentleman
Multiple LTCs and social care needs

21. Patient stories
Social worker
Pre integration Patient story
Unable to accept direct referrals
Referrals going outside of the ICT
Information gathering
82 year old gentleman
Dementia
Post integration Patient story
Information sharing
Able to accept internal referrals
Completion of joint visits
80 year old gentleman
Lung CA

22. 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)

23. 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

24. • 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

25. • The challenges
 Significant work between workshops
 Large resource commitment
 Overcoming organisational boundaries
 Small operational issues having a big
impact

26. 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

27. 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

28. 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 !