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Airedale Collaborative Care Team An Integrated approach Steph Lawrence Team Leader.
An Integrated approach
Steph Lawrence Team Leader
Why did we do it?Community services8 social services rehab beds for 140,000 peoplesmall rapid response serviceNo capacity in community services to support people at homeAcute trustIncreased length of stayDelayed dischargesIntermediate care beds in the acute hospital
What did this mean?PatientsIn acute hospital setting after medically fit for dischargeSecondary problems developingMedical model not close to homeCommissionersIncreasing numbers of A&E attendances and hospital admissionsNo way of reducing acute demand because of community alternativesNo buildings for cost effective beds
Strategy developmentMulti-agency service specification developed by GP allianceOne vision consistent with principles of Intermediate CareConsulted with main providers and GPsFocussed on step up and step down servicesAim to reduce admissions and length of stayPump prime a multi-disciplinary teamContract community beds in the independent sectorDevelop ‘virtual’ beds in patients own homesDecommission intermediate care beds in the acute setting
What does it look like today?A large multi-disciplinary team with single operational line managementIntermediate care beds in two local nursing homesA truly integrated health and social care team delivering care to patients in their own homes and care home bedsClose partnership working with the wider primary care team e.g. Community matrons, GP’s, District Nurses
Benefits of Integrated TeamsSeamless service for patientsQuality service for patientsHolistic service for patientsBenefits to staff including sharing of professional knowledgeBlurring the professional boundaries of how we workRecognition of specialist skills within the teamMore cohesive teamReferral pathways diminished (dealt with in house!)Reduced delays for patients and servicesPatient gets right care at right time in right placePatient central to everything we do “nothing about me without me”Multi-disciplinary led assessments and teamMulti-disciplinary model incorporating medical, social, nursing, therapy etcBetter job satisfaction for staff/reduced stress at having to wait for assessments etcInstant professional advice on tap for assessorsConsideration of carers as well as patients within the serviceEfficiencies and cost benefits due to reduction in delays etc
Challenges of working within Integrated TeamsLoss of professional identity (more a perceived threat than actual)Being open and honest and challenging different cultures etcNeed to compromise on occasions (not patient care)Acceptance of another professionals assessmentCommitment, innovation and drive from the senior team has to be constantNeeds working at, not always easy
How to get there?Constant drive and enthusiasmCan do approach – don’t give up!Open and honest dialogueDon’t always get it right first time – need to learn from this and try againFair and transparent management processSingle operational line management with input from partner organisations re professional supervision/advice Ask for advice – work as a teamNo one professional can provide all that our patients require, it takes team work and commitment