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

2. 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

3. 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

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

5. What do we mean by integration?

6. 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…..

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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

13. Any Questions?