Integrated Community Support Teams

What was the issue you were addressing or working on?

Consultations with all stakeholders prior to this project had identified key issues:

  • Join staff into one team and provide 24 hr community nursing and home care.
  • Make it a neighbourhood model
  • Use existing knowledge, skills and practices.
  • Build in confidence and resilience within the local workforce
  • Retain GPs as the responsible medical officer

The principles mainly being to:

  • Provide effective, person centred support to enable people to remain safely at home for as long as possible
  • Support the person to return home as soon as possible if admitted to hospital
  • Support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

What you did?

The pilot brought together the existing Long Term Nursing Teams (District Nurses) with the evening and overnight nursing service to provide continuous 24 hr care.  The teams include community PT’s and rehabilitation staff transferred from the hospital discharge team.  Additional nursing, physiotherapists, occupational therapists, healthcare support workers and clerical staff were funded by Change Fund.

Home care provision was enhanced to provide 24 hr care and faster access by social work or health professionals to care packages when required to meet the aims above.  A single point of access telephone system for health was implemented funded by NHS locality management.  Processes and procedures were developed in partnership with the multi agency staff and managers to ensure effective communication and enable direct access to the multi agency resources.

The re-enablement and goal setting approach was in use by all social work staff and is now adopted by health care practitioners.  GPs have remained the responsible medical officers.

New and proactive links have been initiated with: acute hospital services, clinicians, discharge staff, specialist staff and 3rd sector agencies.  Improved inter agency IT links and use of a single health IT system for nursing and therapy staff have assisted communication and minimised duplication.

Winner of the Continuity of Care Category, Patient Experience National Awards 2013.  The presentation to the Patient Experience National Awards 2013 is available here.

What were the outcomes - benefits or otherwise?

A full report for the first year 14th May 2012 – 13th May 2013 is available here .  Also available are independent evaluations of patient and carer views here, staff views of goal setting and outcomes here and GP and practice staff views on using ICST here.

Further research on staff experiences within the development of this pilot is currently being completed.  All evaluations showed mainly positive views with some constructive points to inform future practice.

An audit of the impact on GP home visits prior to the start date was repeated the following year. (Minimal change shown.)  The audit is available here

The 24 hour nursing service was an immediate success with older people, their families, carers and staff.

The Community Nursing, Allied Health Professionals and support staff are now operationally managed together.   Although slow to establish fully, this has transformed the access to services for older people in particular.  An added benefit has been the effect on care delivery to all age groups within the locality.  Although not yet co located significant progress has been made to form the basis for this in the future.

Allowing practitioners to inform the development of joint processes has proved effective in building confidence and improving communication.  Those joint processes have proved to be a catalyst in the acceptance and improvement in joint assessments, goal plans and the outcome focused approach recommended by JIT.

As this has been a pilot some staff have a temporary contract.  This has been an inhibiting factor in the recruitment and retention of the workforce.  However there has been no detrimental effect on the delivery of the service.  Older people and their carers continue to applaud this initiative and are expecting it to continue and expand.

Due to the complexity of contributing factors the impact on the acute sector is in an early stage.  However, indications are cautiously optimistic and some of the benefits include: a decline in A&E attendances; shorter lengths of stay in hospital for older people; a positive shift from nursing home admissions to people returning home following complex care assessments; increasing District Nurse complex case loads.

Contacts - to find out more

Morag Hearty,   01355 593450

Marjorie McGinty, Programme Manager,