Integration-improving community care services Eleanor Corbett Integrated Community Lead Lymington Integrated Care Team
Dec 25, 2015
Integration-improving community care services
Eleanor CorbettIntegrated Community Lead
Lymington Integrated Care Team
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
What we did well….
Moving toward integration
Southern Health NHS Trust working towards Integrated Community TeamsIntegrated leadership, whilst still maintaining nursing, AHP and mental health specialitiesNew holistic care models including social , physical and mental health care; aiming to improve outcomes for patientsTeams linking with GP surgeries and aligned with Adult Services boundaries
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
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
02468
101214161820
urgent soon routine
Jun-14
Feb-15
Reduction in therapy waiting times in weeks
Working together
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 regularlyIntegrated Care Team meetings-with Health and Adult ServicesIntegrated OT meetings (Community Team and Adult Services)Joint visits with Therapy, Nursing and OPMH Team
Health Care Support Workers developing competencies to include mental health skillsIntegrated management of pressure ulcers- therapists carrying out postural assessments
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
Questions
Contact details- Integrated Single Point of Access (West New Forest) 01425 [email protected]