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Integrated Teams DH LTC Programme Helen Griffiths Senior Service Improvement Manager

Integrated Teams DH LTC Programme Helen Griffiths Senior Service Improvement Manager Principia Rushcliffe Clinical Commissioning Group (presented by Lynne Cotterill). The Geography. Rushcliffe & GP practices. Nuts & bolts of building an integrated team. Development of team to date

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Integrated Teams DH LTC Programme Helen Griffiths Senior Service Improvement Manager

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  1. Integrated Teams DH LTC Programme Helen Griffiths Senior Service Improvement Manager Principia Rushcliffe Clinical Commissioning Group (presented by Lynne Cotterill)

  2. The Geography

  3. Rushcliffe & GP practices

  4. Nuts & bolts of building an integrated team • Development of team to date • Future • Model • Lessons learned

  5. “Integration” • What do we mean? • Why develop the team? • How to develop the team?

  6. Who’s in the team? Ward Clerk Community Service Advisor Ward Manager Community Matron Nursing Staff DN Team Medical Staff GP OT/PT Primary Care OT/PT SW AHSC Specialist Specialist

  7. Social Worker Community Service Advisors Urgent Community Support Service Dementia Outreach Team Intermediate Care PATIENT District nurses Community Geriatrician Respiratory Consultant Community Matrons Primary Care OT/PT/falls specialist Mental health services older people

  8. Community Ward Model • Risk stratification • Management LTC: • emerging risk • management of unnecessary hospital admissions • MDT meetings • Ward rounds

  9. The teams across the wards…

  10. MDT Good Practice • Shared purpose • Shared goal setting • Increase communication/reduce duplication • GP chair • Risk stratification refreshed • Relevant staff invited • Clinical system projected onto wall • Minuted

  11. Standard MDT agenda • PARR • New referrals • Referrals for urgent community support service • Patients refusing a Community Ward assessment • Gold Standard Framework • Patients appropriate for discharge from the community ward • Any concerns related to packages of care including delays • Current community ward patients who are in hospital • Potential community ward patients in hospital • A&E frequent fliers • Unexpected deaths of community ward patients

  12. ICO Clinician Interviews Need to build on our successes, and continue to broaden membership of the integrated team “I feel we have some very empowered staff who have recognised some new and different ways of working and I would like to see this shared more broadly” “I get a feeling that we have avoided unnecessary hospital admissions because of the teamwork that we have…”

  13. Challenges • Cultural/behavioural change • Managing expectations – patients; clinicians; organisations • Dedicated time • Best practice of MDT meetings • Governance of sharing information • IT systems • Transforming community services • Finance

  14. LTC Management

  15. Management of COPD

  16. John’s admitted to hospital Transferred to community hospital Gaps in communication lead to John’s re-admittance to hospital Discharged with pressure sores Follow up visit by district nurses Jack is a referred to the Community ward Assessed by senior nurse Allocated a case manager Care is organised to include: - Generic support workers - OT/physiotherapist - community nurse Jack gets better, given self care advice and is discharged from the Community Ward Case Studies John and Jack are 87 years old; mobile with the use of a stick; no family support; no previous social care support. They become unwell with a UTI and their GPs carry out a home visit.

  17. 18 days in hospital 39 days in rehab 8 weeks of home care Vulnerable to readmission Substantial trauma to patient Total cost = £14,120 17 weeks home care Patient remained at home Minimum trauma for patient Total cost = £7, 800 Bottom Line John Jack

  18. Key Factors • Owned and driven by clinicians • Clinical champions • Communication • Be realistic - speed of implementation • Phase introduction for community wards and teams

  19. helen.griffiths@nottspct.nhs.uk

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