Integrating Health & Adult Social Care in the Community– N19 Pilot Tessa Cole Project Manager [email protected].

Integrating Health & Adult Social Care in the Community– N19 Pilot

Tessa Cole

Project Manager

[email protected]

Rehabilitation (Physiotherapy or Occupational Therapy)

Social Care Assessment (At home or in hospital)

Reablement

Telecare

Occupational Therapy (Social Care)

District Nursing

Mental health support

Integration with health – on the ground

Social Care & OT

REACH / CRT

Wards and Hospital Social Work

District Nurses

Shared management – common vision

Who’s this now?

What are they here for?

I’ve already been asked this three times?

Int. Care

Co-located – working together in one building

A single team made up of different professionals

Care coordination for patients that need more than 1 service

Patient led goals and support planning

Joint visits and joint assessments

N19 Pilot – what was it?

June 2013 – March 2014

N19 Pilot – what was it?

Multidisciplinary N19 Pilot Team Social WorkersSupport WorkersDistrict NursesOccupational TherapistsPhysiotherapistRehabilitation AssistantMental Health NurseAdmin

Key linksLocal GPsIntermediate care bedsPharmacistVoluntary sectorSpecialist nursesHospital staff Housing

Improve patient outcomes

Improve the patient experience

Reduce unnecessary hospital admissions

Cut out duplication and inefficiences

N19 Pilot – what did we want to achieve?

Case study – Mr G• N19 Social Worker was able to co-ordinate a wide range of health and social care

support to help one man get back on his feet after he was admitted to hospital.

• The social worker visited the patient, Mr G, in hospital to do an initial assessment and sought his agreement for a package of Reablement which started the day he was discharged.

• She visited Mr G at home two days after he left hospital to see how the Reablement service was going and assess his home environment. She also sought Mr G’s agreement to have a physiotherapist visit to help with his mobility.

• The N19 Pilot physiotherapist visited Mr G at home three days later and they discussed Mr G’s goals, which included being able to go shopping again and building up his confidence to go out.

Case study – Mr G• The physiotherapist prescribed exercises for Mr G to do and arranged for the N19

team’s rehabilitation assistant to come and help him practise his outdoor mobility once a week.

• Mr G started practicing his outdoor mobility with a three wheeled walker and a week later was practising with just a stick.

• This way of working worked really well as Mr G was able to see one care coordinator throughout his journey and didn’t have to repeat his story to a lot of different people every time he needed support.

• Three weeks after Mr G started his outdoor mobility he felt well enough to cancel his morning call and he reduced his calls again at his Reablement review a week later. Shortly afterwards he ended Reablement with no on-going care needs and a week later he walked for 45 minutes with his walking stick with the support of the rehabilitation assistant.

N19 Pilot – what did we learn?

Improved patient experience

• Having the same person follow patients from hospital, into their homes and throughout the entire process, providing the patient with a familiar face throughout their journey

• Preventing the need for people to tell their story to different professionals many times

• Ensuring all support was coordinated and that professionals knew what other support was being provided at the same time

• Providing the patient with a single person to contact regarding the support they were receiving as a whole

N19 Pilot – What did we learn?• 84% patients very or fairly satisfied

with pilot services

• 77% patients very or fairly satisfied with how quickly they received services

• 92% patients felt it was clear who was co-ordinating their care

• 85% patients felt the services they received joined up or fairly joined up

‘Hopefully the pilot will roll out. [It] did benefit my mother [People were]

occasionally not singing from the same hymn sheet but [the social worker] pulled it together nicely and acted as co-ordinator

for others – such as OT.’

'[they were the] best one ever, treated me like a human being,

absolutely lovely.'

‘everything was brilliant, I am satisfied with everything, I

couldn’t have asked for more.’

'We had a say in everything. She always asked what we

want’

N19 Pilot – Challenges?

• IT and computer systems

• Data protection restrictions

• Different working cultures across health and social care

So what is next…?

Thank you

Any questions?