1. Community Integrated Teams Penny Davison and Jennifer Wilkie 19th February, 2015
Working together to deliver better health and social care to the people of Sunderland.

2. Vision
The vision to improve outcomes for patients; create access to better, more integrated care outside of hospital; reduce unnecessary hospital admissions and enable effective working of professionals across provider boundaries.

3. Aims
The aims of the Community Integrated Team is for Health and social care professionals to work together to:
Improve people’s experience of getting the health and social care they need.
Deliver better health and social care outcomes by helping people live as independently as possible in their own home with the care and support they need.
Make better use of health and social care resources by getting the right care to people at the right time to avoid unnecessary hospital admissions and appointments where possible.

4. Sam’s Story

6. Community Integrated Teams: What does this mean?
Community nurses and social workers/social care staff will be based together, physically in the same building in each of the five localities.
A named worker who is responsible for co-ordinating a person’s care.
One care plan that pulls together information from all the sources involved in a person’s care.
Avoid duplication – avoid unnecessary appointments or visits by professionals.
Easy to use – know who to contact when you need support.
Partnership with city wide services to offer more joined up care across various providers.
Person-centred – putting people and their families at the heart of all decision making, giving them information and support to make choices about their own care.
Our purpose today is a real example of what it means – multi disciplinary teams wrapped around localities person centred and coordinated care for people.
Some budgets have to go in – others up to local area and CCG intend to put 29m re comm nursing in for example. LA may put in their 35m re care and support – national guidance may require some PC money to go in. Idea is joint decisions and joint responsibility to deliver and joint incentives/penalties if don’t.

7. Community Integrated Teams: What does this mean?
Health and social care workers working together in one team, working as a whole to deliver your care.
Typical person who may benefit from this
Elderly person living with frailty
Severe frailty, history of falls, immobility
on 10 or more prescription medicines
(17% of over 65yrs old or 1 in 6 meet)
have 5 or more long term conditions
(1in 5 over 65yrs olds have 5 or more LTC)
Core components of the Integrated care model in Sunderland
The Integrated care model has been developed to:
Improve communication and allow clinicians to work together across settings of care
Clearly outline the steps required to deliver proactive, person centred coordinated care.
Establish underlying enablers to deliver change including;
Patient and carer engagement
Evaluation framework
Information sharing to enable timely access and analyse data
Organisational development and culture   
Each locality integrated team will develop working practices against one core set of operational principles to ensure shared decision making with patients, carers and other health and social care professionals, including care agencies (where applicable):
Practice based care – Most patients will continue to receive care in their local GP Practice with their GP as their primary point of contact and input from the practice nurse
Practice MDT meeting – A small number of patients will be discussed at practice based MDT meetings
Group Meeting – A very small number of the most complex patients will be discussed at multi-disciplinary case conferences to include input from appropriate providers, this may include a Geriatrician or Mental Health depending on the patients being discussed.
Care Home ward rounds and visits to patients living in their own home- These ward rounds/ visits will include input from GP and Nurse with other professionals identified as required, e.g. Community Geriatrician, pharmacist.
Need to establish how they will be organised in an operational sense in order to deliver the right level of care to patients who most benefit.
A common approach that is based on;
GP Practice Patient Registers
Risk stratification using Emis QAdmissions of patients who are at high risk of being admitted as an emergency
Segment individual patients by risk and knowledge of clinician and professionals
The integrated team should deliver the following functions:
Review, including medication review for all new referrals, and following an emergency admission to hospital.
Creation of individual care plans, including Emergency Healthcare plans, and self-management plans, that are based on the outcomes identified by patients and carers, maximising shared decision making between clinicians, care professionals, patients and carers.
Develop protocols and care packages which will include specific activities, designated care professionals for each activity and resource requirements.
Assign a named individual responsible for ensuring that planned care happens on time and at a high quality.
regular meetings attended by care professionals from different settings and with different backgrounds at practice level.
Foster a culture of continuous improvement and learning, review performance metrics including patient experience, clinical outcomes, financial performance and team effectiveness to identify opportunities for improvement.

8. How are we making this happen?
All partners are working together to implement this in each of the 5 locality areas.
Draft proposals for change will be decided by the CCG in March 2015
Change will begin from April 2015 and will be ongoing

9. Questions/ Discussion
What do you like about this?
What don’t you like?
What would make it better
for you / your family?