The Sedgefield Adult Community Care Partnership Establishing Integrated Adult Community Care Teams P

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The Sedgefield Adult Community Care
PartnershipEstablishing Integrated Adult
Community Care Teams Paul
Irving Director Of Integration
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Agenda

• Why do it?
• The Sedgefield Model
• Implementation
• The Challenges
• How we met the Challenges
• Lessons from the Pathfinder Team
• Where are we now

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Establishing Integrated Teams
- Why do it?
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Policy Framework

• NHS Plan
• Modernisation Agenda
• National Service Framework intermediate care,
  falls prevention
• Planning and Performance Framework Local
  Delivery Plans
• Supporting People

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Not developing the types of care services needed
in the future fast enough - we are too slow!
33 increase in people needing care services in
next 10 years- demand is increasing more quickly
than ever before
We are sometimes providing the wrong services at
the wrong time to the wrong people -we need to
review how and where we spend our resources
Low overall user expectation -user expectations
will increase in both needs wants
A case for improved integrated working in local
communities
The rate of changes in health care must link to
changes in social care and housing provision-The
key providers must co-ordinate their service
changes more effectively
Govt will no longer tolerate poor performance or
slow progress- cash rewards are available to
those willing to change
We are still driving a reactive approach to care
and housing provision- we need to develop
enhanced preventative services
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Users and Carers said
We have to be prepared to Challenge the
Professionals Who Think They Know Best .. We
Actually Do Know What Is best for Us 10 Years
of Talk and Glossy Brochures about Integration of
Services .. Enough Talk .. Just Do It!! User
carer workshops 2003
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AIDS/ADAPTATIONS
HOUSING
N.H.S.
S.S.D.
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The Challenge!!
JOY!
Sedgefield Integrated Team
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The Sedgefield Model
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Overview Of The Design For The Sedgefield
Partnership

• Voluntary agreement to operate in integrated way
  not a care trust
• Integrated working managed by a partnership board
• 5 geographic integrated teams based around
  natural communities
• Co-location of staff from each organisation
• Appropriate access to services 24/7
• Meeting community needs from prevention to direct
  service provision A one stop service team,
  capable of delivering both efficient care to
  people and effective preventive actions within
  their local community

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5 Geographically Based Teams
Health Staff District Nurses Health
Visitors School Nurses Health promotion
staff Mental health link worker Social Services
Staff Social Workers/Social Work Assistants
(Adults) Council Staff Admin and Business
Support Care Link Co-coordinators Services Suppo
rted Housing Officers
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Activities within the integrated teams

• Care Management Process
• Allocation of Referral/work within the team
• Assessing Need Individual and Community
• Planning Care Packages
• Implementing Care Plans
• Commissioning Services to meet health,
  social and accommodation needs/Managing
  Suppliers/ Service Delivery
• Monitoring/Reviewing of on going cases

• Providing
• Nursing Care
• Health Promotion
• Social Care
• Accommodation sheltered, adapted, extra care
• Adaptations
• Therapy Support
• Warden Services
• Decoration/Maintenance Support
• Rehabilitation and Intermediate Care
• Voluntary Agency Links
• Prevention

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Implementation
How we make it happen
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Integrated Support Systems - Key Workstreams
One of the Key Reasons That Integration Fails
Is That the Support systems Are Not put on Line
at the Same Time As the teams .. Bob Hudson
Nuffield Institute
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• Key workstream areas

• IT
• HR
• Training
• Performance Management
• Finance
• Business support
• Legal
• Accommodation
• Communications

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The Challenges We Faced
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Culture Eats Strategy For Breakfast
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Challenges
Culture Differences Staff
- Agencies Delegated Powers -
Local Decision Making v Corporate One Size Fits
All ? Professional Boundaries and
Leadership Finance The Fair Share
Debate Terms and Conditions, Policies And
Procedures
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How We Met These Challenges
High Level Sign Off Commitment Partnership
Board Charter Constitution Design Team
Project management Workstreams Consultation
Staff - Users -Staff
Side Pathfinder Team Training and Team Building
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Lessons From The Pathfinder Team

• Community Partnership Manager role
• Accommodation
• Finance and budgets
• Single Assessment Process
• IM T
• Business Support

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Evaluation

• External expert commissioned to evaluate
  integration
• User carer forum set up locally to help evaluate
• Ongoing surveys of patients and staff
• Business Plan performance
• Statutory indicators and Performance Management

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Where We Are Now
Pathfinder Team Established 5 Community
Partnership Managers in post Remaining 4 teams to
be established April/May Partnership Board
Established Operational Management Group
Established Fair Shares Agreed