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 623802eleanor.corbett@nhs.net