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 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 Medication Dietetics Prescribing Diagnostic skills LTC Management Mental health SALT Palliative care Medication Therapy/Equipment Assessment skills Welfare rights Complex wound management Nursing care Social and personal care Housing Moving and handling Acute Care team

Cons. Memory Cons. Geriatrician CM GP Alzheimer's Society Patient & Partner Age UK DN 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

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

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)

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

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

Next steps Roll out Borough wide summer 2015 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?