Integrated Community Support Team (ICST)

East Kilbride and Strathaven

Liz Swan and Morag Hearty

Key facts: Population 88,000 approx. Above Scottish average older age group Scotland's first “New Town” in 1947 Both urban and rural areas Mixed social strata Large acute hospital –Hairmyres Known locally for its traffic roundabouts,

snow and Strathaven “toffee”.

District Nurses

Physiotherapists

GP

Social workers

Evening nurses

Home carers

Night nurses

Social work OTs

Discharge therapists

Re enableme

nt

Older Person

FamilyOther

specialist

services

We needed to join people up into one team That we should not create a bolt on team Needs to be a neighbourhood model To enhance existing knowledge, skills and practice, building confidence and resilience

of the local workforce To make the model sustainable GP’s wanted to remain responsible medical

officer for patients

Consultation told us…

To provide safe, effective, person centred support to enable people to remain safely at home for as long as possible

When someone admitted to hospital support the person to return home as soon as possible

To support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

ICST Principles

Older Person

ICST24 hour Nursing and Home Care

PhysiotherapistsOccupational Therapists

Social workersRe enablement staff

Carers Support3rd Sector agenciesHospital discharge

Independent Providers

GP

FamilyOther

specialist

services

We thought this was a fob off – how wrong could we have been

It came at the right time

Makes such a difference to work with the physiotherapist

much better continuity of care

A huge weight off my mind

She listened to me-she understood it

Delivered with a smile and a sense of humour!

This is

the future

I was really

impressed how

everybody got

together to do

things

Even during the night-amazing

He is getting

back to being

independent

No way can we go back

It was no

effort for me

I was terrified

to go to sleep –

that has been a

lifeline for me

Adopted across NHS Lanarkshire “Shared Care “ for tier 3 patients Improve use of 3rd sector Direct links with A&E and Scottish

Ambulance service Step down beds in Care homes Co Location Scottish Health and Social care integration

Continue to listen to older people and their carers!

In progress: