Transcript My Life, My Choice

Complex Care Teams
Context
The Department of Health white paper
“Our Health, Our Care, Our Say”
‘By 2008 we expect all PCTs and local authorities to
have established joint health and social care
managed networks and/or teams to support those
people with long term conditions who have the most
complex needs.’
What are complex care teams?
• Health and social care front-line staff supported by voluntary
sector working alongside primary care practices.
• Co-ordinated and timely response to individuals and their
carers with long term conditions and/or complex care needs.
• Proactive approach to identification of people at risk and
provision of a joined up response.
• Complex care teams will reflect the local needs and the
diverse geography of Devon
supporting populations of around 30 – 35,000
• Built on existing best practice in place across Devon
(Learning shared from a formally evaluated pilot in the
St Thomas area of Exeter)
What are Clusters?
• Clusters are integrated health and social care services.
• Grouped together alongside primary care services for
practice populations within designated geographical
communities.
• At the core of a cluster there is a complex care team.
• It is possible in some larger clusters that there will be two
complex care teams.
• Clusters will include services such as local community
hospitals, some core community nursing services and
some specialist NHS or social care services.
• The proposals indicate 16 adult clusters across Devon
with 23 Complex Care Teams.
Key elements of complex care
teams
•
Provides a single point of co-ordination for referrers.
• Delivers a responsive and timely service for the
individual.
• A case management approach for people with long term
conditions and/or complex needs as appropriate.
• Works across organisational boundaries to promote
independence and choice for adults either in their own
homes or as close to home as possible.
How does it work?
• Partnerships with the Voluntary and Community Sector
facilitate access to community based services to
support individual’s well-being
•
Reduces dependence on statutory interventions.
• Utilises a range of ‘case finding tools’ to proactively
identify people who may be at risk of loss of independence
or unnecessary hospital admission.
• Works with an enabling approach that supports self
determination and independence, for example through the
use of direct payments, self care, and self directed support
Key staff
Community nurses
Community matrons
Occupational therapists
Social workers
Community care workers
Domiciliary Pharmacists
Representatives of local voluntary sector
Assistant Practitioners
Rapid Response staff
Physiotherapists
Community psychiatric nurses (for older people)
Approved social workers (for older people
Some public health provider staff
Complex care team co-ordinator
Joint agency administrative and clerical staff
Specialist staff
• Other specialist staff are likely to work across two or more
complex care teams i.e. specialist therapists and nurses, or
sensory workers.
• Some of these staff have other functions and areas of
activity across the local health and social care cluster. Not
all of these roles currently exist consistently across Devon
and there is a need for further workforce planning and
development.
• A joint health and social care manager ‘Cluster Manager’
will be responsible for the operational management of the
complex care teams within a cluster.
Operational Issues
• Accommodation
We are looking into the co-location of some of the functions
and staff within a complex care team.
• Working arrangements
There will be shared working processes and systems to
support the work of the complex care teams enabling
participation by GPs as well as other core team members
and specialist workers, including practice nurses.
• Core multi-disciplinary assessment activity
IT systems, telephony and accommodation will all play a
vital part, Face to face working will need to be established in
ways that recognise the geographical constraints, through
meetings, such as those already well established, variously
described as multi-disciplinary team meetings, core group
meetings, SMART meetings, close to home meetings,
Easicare Meetings.
Performance Indicators
• A range of shared health and social care outcomes are
anticipated including:
• Emergency bed days reduced by 5%
• Reliance on secondary care services reduced
• Timely assessment and care / treatment plans delivered
• Reduced delayed hospital discharges
• Reduced avoidable admissions to long term care
• Provision of care in a primary, community or home
environment increased.
• Individuals with long term conditions receiving high
quality care personalised to meet their individual
requirements.
• Improved support to carers to enable them to remain in a
caring role.
• An effective, systematic approach to the care and
support of people with a long term condition embedded
into local health and social care communities.
When will these arrangements
be in place?
• There is already good local evidence of integrated
working in place across Devon. We expect the roll out of
complex care teams to accelerate from Spring 2008.
• Completion will be by May 2009.
Thank you very much
for listening
Questions are very welcome