1. Integration-improving community care services Eleanor Corbett Integrated Community Lead Lymington Integrated Care Team

2. Background 2 Community Care Teams with Nurses, Physios, OTs and Health Care Support Workers Increasing demand on service Long therapy waiting lists in 2014- patients waiting over 18 weeks for routine therapy appointment Low staff morale, complaints from patients, not meeting Trust’s targets High number of avoidable pressure ulcers

3. What we did well….

4. Moving toward integration Southern Health NHS Trust working towards Integrated Community Teams Integrated leadership, whilst still maintaining nursing, AHP and mental health specialities New holistic care models including social, physical and mental health care; aiming to improve outcomes for patients Teams linking with GP surgeries and aligned with Adult Services boundaries

5. Reduced therapy waiting lists Case load cleanse Introduction of dependency tool to aid allocation of work Upskilling staff Single Point Of Access booking new appointments Clinics set up- falls prevention and physio Senior Therapist triaging referrals daily 2 x Duty therapists providing cover from 8.30-18.00 Mon to Fridays

6. Now…. Referrals triaged daily and Patient contacted within 24 hours with appointments Rapid referrals seen within 2 hours Urgent referrals seen within 48 hours Soon referrals seen within 2 weeks Routine referrals seen within 3-6 weeks Patients with pressure ulcers (grade 2 and above) assessed by senior therapist within 48 hours

7. Reduction in therapy waiting times in weeks

8. Working together

9. Integrated working Integrated Single Point of Access (includes OPMH) Development of Integrated Community Lead posts Virtual ward and practice ward meetings, including Consultant Geriatrician. TVN attends regularly Integrated Care Team meetings-with Health and Adult Services Integrated OT meetings (Community Team and Adult Services) Joint visits with Therapy, Nursing and OPMH Team

10. Health Care Support Workers developing competencies to include mental health skills Integrated management of pressure ulcers- therapists carrying out postural assessments

11. Where next? -Review of skill mix -Development of individualised well-being plans -Nursing and Therapy staff to work with OPMH Team to promote physical well-being of patients with dementia -Build links with Voluntary sector -Working towards integrated triage and rapid response service -Building links with hospitals -Review number of avoidable pressure ulcers

12. Questions Contact details- Integrated Single Point of Access (West New Forest) 01425 623802 eleanor.corbett@nhs.net