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?