1. July 2008- Caring for Devon briefing on Complex Care Teams

2. 2 Caring for Devon Improved way of working: Cluster Service Model The attached diagram illustrates the context in which Complex Care Teams will operate within their Health and Social care cluster areas. The central CCT section indicates the core activity of complex care teams: case management for very high intensity users. As such, the community matron role rests entirely within this section. Other aspects of community nursing, therapy, primary care, social care, OPMH services and community hospitals will all have a vital part to play in the delivery of care to this group of patients. They may deliver a full case management function, or offer specialist interventions to people receiving case management.

3. 3 Caring for Devon Improved way of working: Cluster Service Model The darker blue circle indicates that each of these groups of staff and services also deliver interventions to people who have lower level needs and represents those single service, time limited interventions with more predictable outcomes or specialist services provided within hospital or primary care settings. The Health & Social Care Cluster Manager provides the continuity of line management support that brings all of these factors together into a coherent operational model Case studies of the outcomes for 2 clients are provided by the Exeter complex care team pilots, these illustrate well the benefits that can and will be achieved by this model

4. 4 Caring for Devon

5. 5 How does this work with Social services?- an improved way of working: Telephone based: Care Direct Plus- Assessment Care Planning Reviews Arrange services Hospital discharges Face to face: Complex Care Teams- Long term, complex conditions Assessment Care Planning Reviews Telephone based: Care Direct- Benefits check FACS check Information Advice Rapid Equipment & minor adaptations Social care Moving & handling Major adaptations Information and advice Switches on ALL services Professionals New Known to have social services Known to have a current case manager Health to health referrals Hospital Discharge Public Specialist- Mental Health Specialist- Learning Disability Specialist- Sensory

6. 6 Caring for Devon Improved way of working: BENEFITS The REMAS supplies and fits minor equipment and adaptations to aid mobility and promote independence. It is a speedier service, has reduced waiting times and waiting lists and is less costly. The resolution of client contacts, within the Exeter & East Devon CD Plus pilot, within 5 days is 82%. This is a striking improvement on previous performance. Brokers set up services for both CD Plus and Complex Care Teams, also for specialist services in Learning Disabilities, Adult Mental Health and Physical Disabilities. More stream lined and effective. All of this means that more specialist staff ( 55% of the workforce) have more time to focus on the management of complex activities (35% of clients). They can, therefore, be more effective and do a better job.