Airedale Collaborative Care Team An Integrated approach Steph Lawrence Team Leader Why did we do it? Community services 8 social services rehab beds for 140,000 people small rapid response service No capacity in community services to support people at home Acute trust Increased length of stay Delayed discharges Intermediate care beds in the acute hospital What did this mean? Patients In acute hospital setting after medically fit for discharge Secondary problems developing Medical model not close to home Commissioners Increasing numbers of A&E attendances and hospital admissions No way of reducing acute demand because of community alternatives No buildings for cost effective beds Strategy development Multi-agency service specification developed by GP alliance One vision consistent with principles of Intermediate Care Consulted with main providers and GPs Focussed on step up and step down services Aim to reduce admissions and length of stay Pump prime a multi-disciplinary team Contract community beds in the independent sector Develop ‘virtual’ beds in patients own homes Decommission intermediate care beds in the acute setting What does it look like today? A large multi-disciplinary team with single operational line management Intermediate care beds in two local nursing homes A truly integrated health and social care team delivering care to patients in their own homes and care home beds Close partnership working with the wider primary care team e.g. Community matrons, GP’s, District Nurses Benefits of Integrated Teams Seamless service for patients Quality service for patients Holistic service for patients Benefits to staff including sharing of professional knowledge Blurring the professional boundaries of how we work Recognition of specialist skills within the team More cohesive team Referral pathways diminished (dealt with in house!) Reduced delays for patients and services Patient gets right care at right time in right place Patient central to everything we do “nothing about me without me” Multi-disciplinary led assessments and team Multi-disciplinary model incorporating medical, social, nursing, therapy etc Better job satisfaction for staff/reduced stress at having to wait for assessments etc Instant professional advice on tap for assessors Consideration of carers as well as patients within the service Efficiencies and cost benefits due to reduction in delays etc Challenges of working within Integrated Teams Loss of professional identity (more a perceived threat than actual) Being open and honest and challenging different cultures etc Need to compromise on occasions (not patient care) Acceptance of another professionals assessment Commitment, innovation and drive from the senior team has to be constant Needs working at, not always easy How to get there? Constant drive and enthusiasm Can do approach – don’t give up! Open and honest dialogue Don’t always get it right first time – need to learn from this and try again Fair and transparent management process Single operational line management with input from partner organisations re professional supervision/advice Ask for advice – work as a team No one professional can provide all that our patients require, it takes team work and commitment Questions?