Integrated working- Integrated Neighbourhood Teams & Neighbourhood Networks Nic Roper, Area Manager- Suffolk County Council

What’s the background? Long standing knowledge that integrated care will provide a better health and care system for people – but in East and West Suffolk partners were struggling to make this a reality at scale The Health and Care Review – started in December 2012 - aimed to create a shared view of a future integrated system The vision and service model has been signed up to by all partners, and has informed the Suffolk Better Care Fund Plan Partners are now committed to delivering the new model of care – Connect Sudbury and Connect East Ipswich are the forerunners for the new system 2 main building blocks for integrated working in Suffolk: Neighbourhood Networks & Integrated Neighbourhood Teams

The Neighbourhood Network: a person’s support network Community Groups Employment Neighbours Clubs Local Shops Schools Family Local Services GP Friends Integrated Neighbourhood Team (INT) – multi agency team Church Supporting the individual to remain healthy, active and engaged in their community

Integrated Neighbourhood Team (INT) – Local Shops Integrated Neighbourhood Team (INT) – multi agency team GP

Neighbourhood Network aspirations Information- Good clear, easily accessible local information, supporting independence, self reliance, confidence and self-care Connectedness - Easy or supported access for individuals to connect with others. Good knowledge within organisations about others Age and disability friendly communities- Accessibility to employment, services and leisure opportunities etc Voluntary and Community Sectors- Thriving, supportive alliances of local voluntary sector organisations. Well known and well used local groups and activities Behaviours- No wrong door; widely adopted strengths-based approach; warm handovers; respect between people and organisations within a person’s Neighbourhood Network and statutory services for knowledge and skills held

Developing community capacity- what’s already happening? Local networking events Dementia Friendly Communities New Infolink website: http://infolink.suffolk.gov.uk/kb5/suffolk/infolink/home.page Voluntary and Community Sector scoping Introduction of Local Area Coordination Community pharmacies Community Safety Health and Wellbeing Board and voluntary sector partners’ campaign to reduce social isolation and loneliness across the age range

The Neighbourhood Network & the Integrated Neighbourhood Team Community Groups Employment Neighbours Clubs Local Shops Schools Family Local Services GP Friends The people and places that keep people resilient and happy. Where NN overlap – communities of interest Church

The Integrated Neighbourhood Team Early intervention Local Area Co-ordinator VCS Self Management CYP Prevention District/ Borough Council ACS GP Primary care Suffolk Community Health Home First Police Housing Interface Geriatrician Mental Health Person centred Getting to know each other: INT Directory Workplace shadowing Life Timeline tool INT Toolkit

The Community Health & ACS Social Care part of the team Early intervention Local Area Co-ordinator CYP Self Management VCS Prevention District/ Borough Council GP Primary care Home First ACS/ Suffolk Community Health Police Interface Geriatrician Mental Health Housing Person centred Key deliverables for Health & ACS: Tight integrated partnership which is co-located with shared processes, changing business as usual IT pilot but also interim tactical solutions for joint assessments, single plans, single view/ accountable worker Generic skill bases Operational Manual

Creating opportunities for wider integrated working- an Enhanced Health & ACS MDT…. Housing VCS MDT Co-ordinator GP SW District Nurse Community Matron OT Physio Mental Health Link Worker Practice Staff Home First CYP Local Area Co-Ordinator Police District/ Borough Council Creating enhanced MDTs: Learning from the best Effective Risk Satisfaction/ case finding

… possible other wider Enhanced MDTs MDT Co-ordinator GP SW District Nurse Community Matron OT Physio Mental Health Link Worker Practice Staff Police Mental Health ACS Ambulance Service CCG ACS GPs High demand families Health & ACS MDT Care Homes Learning from the ACS & Health Enhanced MDT Hot desking opportunities Co-location opportunities Integrated Learning Sessions Data sharing protocols

Phased implementation Health & Social Care integration INT Directory Workplace shadowing Operational manual INT Toolkit Co-location Hot desking Learning sessions IT pilot MDTs GP Practice 1 GP Practice 2 GP Practice 3 GP Practice 4 GP Practice 5 Wider multi agency integration