Integrated teams The journey so far Mark Girvan

Integrated teams – The journey so far…… Mark Girvan, Reform Manager, NECS Diane Shotton, Safe Care Lead, South Tyneside Hospitals

Aims of Integrated Teams • South Tyneside CCG and South Tyneside Council Social Care workforce in partnership to develop a shared vision for health and social care integration • 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

Current provision • Number of different teams, individuals and providers delivering a range of health and social care tasks Medication Prescribing Dietetics Diagnostic skills LTC Management SALT Mental health Palliative care Medication Therapy/Equipment Welfare rights Housing Assessment skills Complex wound management Nursing care Social and personal care Moving and handling Acute Care team • Current workforce capacity; – 150 WTE Community nurses – 11 Home Care providers – 60 WTE social care • Hand offs’, fragmentation, duplication, limited information sharing • Opportunity to improve patient experience

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

What do we mean by integration?

Developing the Model • Series of development sessions with stakeholders • LOTS of discussion and views on how the model should work • Local, national and international review of best practice • Patient/Client remains at the heart • Prototype model designed…. .

Key Principles • Delivery team follows the patient and bases caseload on practice populations • Delivery team will operationally take localised/neighbourhood approaches in ways of working • Teams can flex according to primary demographics to best meet identified needs and JSNA issues

Phased Implementation East hub West hub Hebburn/Jarrow Delivery Team A Delivery Team C Delivery Team B Practices (See below) Practices TBC South Shields Whitburn/ Cleadon/Boldon No. of delivery teams TBC No. of Practices TBC Prototype Delivery Team A The Glen The Park South hub Ellison View In place from 20 th November 2014

Establishment of prototype team • Skill mix – 2 x Social workers – 1 x Occupational therapist – 3 x Band 6 nurses – 6 x Band 5 nurses – 2 x Band 3 nurses – 1. 5 x Community matrons – 1 x Social navigator • Underpinned by IT • 1 single contact number • Centrally located (Palmers)

Cons. Geriatrician Cons. Memory ACT 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. GP ICT Integrated Team – Care Coordinator Age UK Alzheimer's Society Care Provider Patient & Partner

Early feedback Positives Challenges Excellent patient feedback Role duplication Shared inter professional knowledge Operationally restricted (double running) Reduced visits Restricted to Mon - Fri Joint visits Integrating referral processes Staff knowledge/up skilling Administrative support Information sharing Blurring of roles Staff satisfaction

Next steps • Plan for roll out across Jarrow and Hebburn early 2015 • Continued Development of evaluation metrics – How will we know if it’s been a success? • Develop engagement and communications strategy Roll out Borough wide summer 2015

Any Questions?