What is it?
This is a programme of work to fundamentally see how community service work with each other. The programme will see the true integration of community service teams from the Pennine Care Foundation, Social Care Trust, and Oldham Council in the Oldham West Cluster. These service teams include: Social Care teams, district nurses, Healthcare Assistants, and the Specialist Palliative Care nurses. The team will also work closely with the Age UK PiP worker, as well as an Action Together representative.
What does it aim to achieve?
The integration of these teams, centred around the ten GP practices within the Cluster, will help to improve patients experience and outcomes, as f the various teams are now able to work closely together to deliver cross-specialism response to patients’ needs. The ability to work closely together, and share data, enables far better health and care outcomes to be delivered.
Case Study 1
District nurses visited for wound management in multiple areas due to the patient scratching his skin. The patient’s spouse spoke to the nurse and confided in her that she was really struggling to maintain the level of care needed and that she felt trapped within the confines of her home.
Support from the Integrated Team
The Social team visited the day after and organised for the spouse to have a full Carer’s Assessment as she appeared very vulnerable. Rotational respite was put into place, as well as day care. This have given Mrs A opportunities and peace of mind to do things herself, such as visiting friends and family.
Prior to integrated working, this particular case would have been referred to the Multi-Agency Safeguarding Hub via a phone call or e-mail, followed by a first contact and screening process. The case would then have been transferred to the Neighbourhood Active Intervention Team and onto a waiting list, which is currently at around 8 weeks for awaiting allocation.
Case Study 2
Complex case; poor living circumstances; depression and anxiety
Support from Integrated Team
Full IMDT review to find a pro-active support plan. Social Services retrieved Patient B’s archived records to get a full case history, joint visits arranged with the GP and the Mental Health team to review relapse indicators.
Full background information gathered from knowledge shared in Cluster team. This process would have taken much longer prior to integration.
Support and care package put into place and housing situation resolved. Patient B now has an allocated LD working and care plan, and support is meeting needs to avoid behaviours escalating to a point of crisis.