Frequently Asked Questions (FAQ’s) v3 18 August 2014
Integrated Health and Social Care Teams for Frail Older People and People with Multiple Long Term Conditions
The Team
Who will be a core member of the integrated
health and social care team?
The team will comprise of professionals from across the health and social care sector; community matron, district nursing, GPs, primary care practice
nursing, physiotherapy, occupational therapy, social workers and care managers, support workers, voluntary sector coordinator, administrator. Each
member of this team, depending on the care needed, may become a care coordinator for a number of patients and their carers.
Case finding/early identification based on risk stratification.
Personalised assessment and care planning.
Early intervention and initial treatment.
What will be the role of the team?
Case management and care coordination.
Treatment, support and review.
End of life care.
Safeguarding.
The locality team will operate from 8am to
8pm, seven days a week. Can you tell me
what will happen outside of those hours?
Who will have access to the team? What are
the acceptance criteria?
Will provision in each locality reflect different
needs within the population?
All patients will be allocated a care coordinator and this person or a designated colleague when they are on leave, will be your main point of contact during
normal working hours, between 8 am and 8 pm. The care plan will provide you with information about what to do in the event of an emergency or a crisis in
and out of normal working hours. You and your carer will be given all the support you need to understand how to access this service. If you do need to
contact your care coordinator out of hours and they are not available you may be directed to the duty staff at the point of access). This person will have
access to your care plan and care record, should you agree for them to have that access, and will be able to arrange the help you need.
Older people who are frail and/or people aged 18 and over with long term conditions who are registered with a Dorset, Bournemouth or Poole GP. People
aged 18 and over requiring community nursing and therapy care and support.
The acceptance criterion is as follows; the person requires nursing, therapeutic or social care assessment, treatment and support (securing social care
funded support for domiciliary or residential care will be subject to a financial assessment).
Yes. Commissioners expect providers to comply with the service specification, e.g. key features, functions and outcomes, however we recognise that
some variation in the operating models is justifiable to reflect each individual locality’s circumstance.
Care homes, voluntary sector providers, specialist community health teams (intermediate care teams, reablement, rapid response, rehabilitation, respiratory
nursing, palliative care, heart failure nursing etc.).
Community services (podiatry, dietetics, SALT, audiology, steps to well being).
Social care services, community equipment, community alarms service.
Who will the core team link with to bring in
specialised services?
Domiciliary care providers, the ambulance service, primary care out of hours, acute hospitals including A&E, community hospitals, mental health and
memory assessment services, carer support services, housing support, pharmacy and medication review services, employment services, learning disability
and substance misuse services.
Overnight services; urgent and planned care and home adaptations and equipment services. Specialist services will be encouraged to provide a named
link for each of the 13 locality teams.
This list isn’t exhaustive.
Will all locality teams operate the same work
pattern or is their scope for change?
The core service will operate 8am - 8pm seven days per week. This was agreed because evidence suggests that the majority of demand happens
between 8 am and 8 pm.
Will the new teams be piloted first?
There will be a phased implementation rather than a pilot.
The Care Coordinator
How many care coordinators will there be in one locality team?
Each patient and their carer will be allocated a care co-ordinator. Each member of the team, depending on the type of care
support required, could have a number of patients for whom they act as the care coordinator. Each care coordinator will
Frequently Asked Questions (FAQ’s) v3 18 August 2014
have a number of patients for whom they are responsible.
What will be the maximum number of patients and carers a care coordinator
can manage at any one time?
In securing the service the providers will be required to use evidence, where available, to inform caseload management.
Will lower banded care co-ordinators be taken seriously?
All team members will have the responsibility to ensure that the individual’s care is effectively co-ordinated. The named care
co-ordinator will reflect the need of the individual e.g. we would expect more complex cases to have a higher banded care
co-ordinator. The care coordinator could be a district nurse if the main need was nursing or it could be a volunteer
coordinator if the main need was help in the home, shopping, befriending services, day clubs and community support. The
team will meet regularly to discuss all case work and care plans and to make changes to them should their needs change.
What will happen when the care coordinator goes on holiday or is sick?
The care coordinator operates as part of a team in which cover arrangements will be a team responsibility. Planned absence
e.g. holidays, will be covered by a single named other care co-ordinator. Unplanned absence e.g. sickness, will be covered
from within the team.
The team will not operate overnight but all patients and carers will be informed about the action to take in the event of an out
of hour’s crisis or emergency. This will be recorded in the care plan.
Can unregistered members of staff become care coordinators?
All team members can be care co-ordinators i.e. the role is not reserved for registered professionals. The care co-ordinator
will be identified depending on the complexity and needs of the individual.
What will happen if a care coordinator or member of the integrated locality
team leaves their employment?
We hope that the creation of the integrated teams and care co-ordinator role will help reduce staff turnover, but turnover is
inevitable. In the event of a care co-ordinator resigning a new care co-ordinator will be appointed as quickly as possible with
another member of the team providing cover until the new care co-ordinator takes up post.
Will the care coordinator focus on medical need only?
No. The role is to oversee the meeting of health and social care needs. The service specification makes it clear that this
includes factors such as housing and psychological needs as well as health and ‘traditional social care’.
The Care Act 2014
How will the requirements of the Care Act 2015 impact on the implementation
of these new locality teams?
The Care Act places certain statutory responsibilities on Local Authorities; to provide information and advice to all people
requiring care and support including self funders, to provide people and their carers with an assessment and recognising
carers in law, to provide advice on personal budgets, to place financial caps on care and making it clearer on what the cost
may be to the patient through a care account, to safeguard adults from abuse and neglect similar to what has been provided
in law to children for many years, to provide care and support and continuity of care even if the person moves across
geographical boundaries.
As you can see, the Care Act legally requires the health and social care sector to put patients and their carers first, to put
them at the centre of any care plan that is arranged for them. This means that the role of the care coordinator and the
integrated locality team is critical and central to the success of this provision; the core team will manage the most common
ailments and will coordinate the care plan but they will also be able to call on specialists through a network of link workers.
How will having a named GP for all people over 75 benefit patients?
The GP is an integral member of the locality team. The care coordinator and members of the team will work closely with the
GP to make sure the patient and their carer are getting the best care possible. Some of the GP’s work will be to identify
patients who may be at risk early and to put in place preventative measures so that injury and the need for hospital
admission can be minimised. Although there will be no age limit to risk stratification, those patients aged 75 and over and
who will have a named GP will act as a focal point for development and provision of preventative services.
Patient and Carer
What happens if I as the carer need help but the person in need of care
refuses to be helped?
The carer will be referred to the carer support services.
What would happen if I as the main carer could not cope?
The care coordinator will make provision in the care plan for the carer’s well being, and the appropriate support put in place. .
What would happen if I as the main carer disagreed with the care plan?
The care co-ordinator will co-ordinate the care for the patient and will ensure your needs are understood and met. Where
views differ there will have to be some arbitration, advocacy support may be appropriate.. It is not envisaged that the views
of the patient and the carer will be so opposed that a care plan cannot be developed. Patients and their carers will not have
separate care coordinators.
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IT, technology and processes and procedures
Will technology be used to support the teams?
Yes. Individual assessments will include consideration being given to the use of assistive technology.
How will we share information without integrating IT systems?
We acknowledge that sharing information across different platforms will be a challenge but it is possible. A care record and
care plan that can be shared and accessed by a multiple number of professionals, if permission to do so is granted by the
patient, is a key piece of this work. Sharing information across platforms and having shared assessment processes and not
repeating assessments and duplication of care plans and records will have a positive impact on the workload of the locality
team and of the patient and their carer. Partners have already submitted a bid to the Integrated Digital Fund to support this
work.
Access to Services
How do homeless people, not registered with a GP, access the service?
Homeless people are not excluded from accessing the teams and can be referred in via any of the proposed referral routes.
But if homeless people require primary medical services support, they would need to become a temporary resident
registering with a Dorset, Bournemouth or GP.
What will happen if a patient moves home?
If the move is out of area or out of the locality provision will be made to transfer the care plan to another team. Information
sharing protocols and a common assessment framework will reduce the time it takes to make this transfer.
Is working to GP populations a problem for social care provision?
The principle that has been agreed is that all team members will work to the same team boundaries. Providers will be
required to give assurance about how this will be achieved as part of the implementation process.
How will teams work when health and local authority boundaries are currently
different?
The principle that has been agreed is that all team members will work to the same team boundaries. Providers will be
required to give assurance about how this will be achieved as part of the implementation process.
How will you connect with people who are socially isolated?
Case finding and the associated referral pathways will be through several routes e.g. GPs, other statutory services, the
voluntary sector, and the patient and their families.
If much of the focus is on preventative action, building community capacity to
deliver non-statutory services seems to me to be a key requirement. How will
you achieve this?
You are right. The voluntary sector is a key feature of this work and although it already plays a vital role in working with
people in the community it will play an even greater role in the future. In response to this an ‘Early Help’ Better Together
work programme has been established. This will look at how the voluntary sector can be supported to widen their reach.
This is also why a volunteer coordinator is a core member of the integrated locality team.
How will the team manage social isolation which is a major concern within
local communities?
The voluntary sector has an important role to play in reducing social isolation. Each team includes a voluntary sector coordinator to act as the bridge between the person, their care co-ordinator and the wider team, and the voluntary and
community sector.
How will the patient’s spiritual needs be met?
The voluntary sector co-ordinator’s role would extend to linking the patient to faith groups etc.
Will nutritional need be catered for in the assessment?
Yes. This has been reflected in the revised specification.
What will happen to existing referral routes?
They will remain but the referral criteria will be standardised.
Is the single point of access (SPA) Dorset-wide; locality-wide; or another
variation?
Existing referral routes including existing SPAs will be retained but, we do expect that a consistent approach to using service
entry criteria will be applied across all access points.
How will housing and equipment services be accessed?
If on assessment a housing or equipment need is identified, specialist support will be accessed through the locality team.
Why does the new locality team not include the following specialists/specialist
support as core members of the team:
There is no argument that these services will be called upon to support patients and their carers and to help them live more
independent lives and there will be key workers in place who will have regular contact with the locality team should their
specialist service be required. Most of these services however are needed for a limited period of time whereas the support
provided by the core team is likely to be more prolonged and longer term in nature. A balance has to be struck but this does
not mean that changes cannot be made as the provision matures, especially as rural and urban localities may have different
key needs and requirements.
Intermediate care practitioners (local authority reablement and NHS
rehabilitation services)
Community pharmacists
Community geriatrics
Substance Misuse
Learning disability
Speech and language therapy
Carer support
Night care
Parkinson’s disease
It is recognised that the dynamic of relative demand and capacity in rural areas suggests that close working between
services or a merger could be beneficial. In this context we wish to make three observations:
1) Operating models in different localities may have some differences to reflect demographics, population size and
urban versus rural characteristics. The key is that the key features, functions and outcomes of the integrated teams
are achieved.
2) Best practice models streams out planned and urgent responses. The disadvantage of merging intermediate care
Frequently Asked Questions (FAQ’s) v3 18 August 2014
MS
Epilepsy
Diabetes nursing
Older people’s mental health services
and the integrated locality teams is that the current issue of reliance on urgent services and a less pro-active planned
approach is exacerbated.
3) In the business case modelling we are anticipating a growth in patient numbers which should increase demand and
therefore the capacity needed (this effect is also likely to be mirrored within intermediate care services). We
anticipate this growth meaning it will become, over time, more realistic to make a distinction between the intermediate
care and locality teams in all localities.
All of the above of course doesn't mean co-location of teams would not be a valuable approach.
It is not possible to provide every locality team with specialists as core members of the team without rationing the service
across Dorset. There are not enough specialist and those that there are have to be used wisely and directed at where the
need is greatest.
This new model is designed to provide care for frail older people with multiple
or long term conditions. How will younger people with long term conditions
be cared for?
The model fails to take account of the role of community hospitals. How are
these included in the delivery of care?
It is hoped that the model for integrated care will be expanded as it embeds into each locality but in recognition of concerns
raised provision will be expanded to include people under 65, but over 18 years of age who have long-term conditions. This
now includes people with learning disabilities who also have a physical health long-term condition.
The integrated locality teams will be responsible for partaking in continuing healthcare assessments (CHC). Patient being
funded through CHC are entitled to mainstream services to meet their assessed needs.
The service specification states that “the service will work with secondary care partners to facilitate appropriate discharge out
of hospital i.e. by providing in reach into acute and community hospitals”.
Care co-ordinators will be expected to liaise with community hospitals, including ‘in-reaching’ to community hospitals when
their patient is admitted and assisting with discharge planning.
Funding and Budgets
How will patients currently receiving continuing healthcare (CHC) be provided
for?
These patients will be managed by the teams in the same way as all other patients. If people are in receipt of CHC funding
they will not be excluded from receipt of the integrated team service.
How will the teams work in a world of personal health budgets?
A key theme is a person centred approach which includes the availability of personal health and / or social care budgets for
people meeting the relevant eligibility criteria. Support will be given to people to work with personal budgets.
Will budgets be pooled across health and social care?
Commissioning partners are exploring the appropriate financial arrangements to support integrated provision. This may
result in a pooled budget. There are also incentives for organisations to pool funds through the Better Care Fund which are
being explored.
How will the integrated locality teams be funded if their funding is premised
on a reduction in acute hospital admissions which may not occur
immediately?
This will be worked through in the business case.
Care Plans and Care Records
How will copies of care plans and care records be provided?
They will be provided electronically or in paper format.
Will care plans and records be shared with other health and social care
professionals?
Yes, if you give permission to do so. It will help professionals respond quickly to your care needs if your care plan and care
record is shared. It will be shared on a “needs only” basis.
Workforce Development, Leadership and Management
How can we be assured that staff in these teams will be given appropriate
training to fulfil their new role?
Providers will be expected to provide suitably qualified and trained staff.
The need for cultural change amongst leaders, managers and staff e.g.
treating the patient as an equal in the care plan, a move away from ‘doctor
knows best’ is important. How will this be achieved?
We agree. Cultural change and developing new ways of working are key elements of this proposed service and programmes
of work, through the workforce development work stream of the Better Together programme will be developed to
accommodate this requirement.
How will the teams be managed?
Each locality team will have a single line manager.
Who will be accountable should things go wrong?
Each professional within the team will have their own professional accountability in addition to existing organisational
Frequently Asked Questions (FAQ’s) v3 18 August 2014
accountability arrangements.
This will need strong leadership for it to work. How will this be achieved?
Leaders at all levels are engaged with this programme but leaders will have to be prepared to allow staff the autonomy to
make decisions and to do what they think is best for the patient. A separate better Together Workforce development
workstream is working alongside the locality workstream to make sure training and development, cultural change, career
enhancement and career pathways etc are looked at and adapted where necessary to meet the needs of the new locality
team and the wider health and social care sector. This includes working strategically with leaders to make this work.
Co-location of staff is unlikely to be enough to make this work. How will you
achieve this change?
We agree, so will enable change through other levers such as contractual changes (e.g. the service specification); single line
management of health and social care staff; integration of electronic records etc.
Safeguarding and Protection
How will this change affect a person’s capacity to make decisions?
How will safeguarding of patients be assured?
We see no reason to apply different protocols and rules from those currently operating with regard to an individual’s capacity
to make decisions about their care.
The locality team has a statutory responsibility for safeguarding adults. This is a recent change in the law,
enshrined in the Care Act 2014.
End of Life Care
Will I be allowed to die at home and be supported at home if that is my
wish?
The teams will provide end of life care and be supported by palliative care specialists. This will include training in
having end of life conversations with patients and their families.