Integrating Health

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Integrating Health Adult Social Care in the
Community N19 Pilot
Tessa Cole Project Manager Tessa.Cole_at_islington.
gov.uk
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Social Care Assessment (At home or in hospital)
Rehabilitation (Physiotherapy or Occupational
Therapy)
Reablement
Occupational Therapy (Social Care)
Telecare
District Nursing
Mental health support
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Integration with health on the ground
Shared management common vision
Wards and Hospital Social Work
Social Care OT
District Nurses
REACH / CRT
Int. Care
Whos this now?
Ive already been asked this three times?
What are they here for?
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N19 Pilot what was it?
A single team made up of different professionals
Co-located working together in one building
Care coordination for patients that need more
than 1 service
Joint visits and joint assessments
Patient led goals and support planning
June 2013 March 2014
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N19 Pilot what was it?
Multidisciplinary N19 Pilot Team Social
Workers Support Workers District
Nurses Occupational Therapists Physiotherapist Reh
abilitation Assistant Mental Health Nurse Admin
Key links Local GPs Intermediate care
beds Pharmacist Voluntary sector Specialist
nurses Hospital staff Housing
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N19 Pilot what did we want to achieve?
Improve the patient experience
Improve patient outcomes
Reduce unnecessary hospital admissions
Cut out duplication and inefficiences
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Case study Mr G

• N19 Social Worker was able to co-ordinate a wide
  range of health and social care support to help
  one man get back on his feet after he was
  admitted to hospital.
• The social worker visited the patient, Mr G, in
  hospital to do an initial assessment and sought
  his agreement for a package of Reablement which
  started the day he was discharged.
• She visited Mr G at home two days after he left
  hospital to see how the Reablement service was
  going and assess his home environment. She also
  sought Mr Gs agreement to have a physiotherapist
  visit to help with his mobility.
• The N19 Pilot physiotherapist visited Mr G at
  home three days later and they discussed Mr Gs
  goals, which included being able to go shopping
  again and building up his confidence to go out.
•  

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Case study Mr G

• The physiotherapist prescribed exercises for Mr G
  to do and arranged for the N19 teams
  rehabilitation assistant to come and help him
  practise his outdoor mobility once a week.
• Mr G started practicing his outdoor mobility with
  a three wheeled walker and a week later was
  practising with just a stick.
• This way of working worked really well as Mr G
  was able to see one care coordinator throughout
  his journey and didnt have to repeat his story
  to a lot of different people every time he needed
  support.
• Three weeks after Mr G started his outdoor
  mobility he felt well enough to cancel his
  morning call and he reduced his calls again at
  his Reablement review a week later. Shortly
  afterwards he ended Reablement with no on-going
  care needs and a week later he walked for 45
  minutes with his walking stick with the support
  of the rehabilitation assistant.

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N19 Pilot what did we learn?
Improved patient experience

• Having the same person follow patients from
  hospital, into their homes and throughout the
  entire process, providing the patient with a
  familiar face throughout their journey
• Preventing the need for people to tell their
  story to different professionals many times
• Ensuring all support was coordinated and that
  professionals knew what other support was being
  provided at the same time
• Providing the patient with a single person to
  contact regarding the support they were receiving
  as a whole

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N19 Pilot What did we learn?
Hopefully the pilot will roll out. It did
benefit my mother People were occasionally not
singing from the same hymn sheet but the social
worker pulled it together nicely and acted as
co-ordinator for others such as OT.

• 84 patients very or fairly satisfied with pilot
  services
• 77 patients very or fairly satisfied with how
  quickly they received services
• 92 patients felt it was clear who was
  co-ordinating their care
• 85 patients felt the services they received
  joined up or fairly joined up

everything was brilliant, I am satisfied with
everything, I couldnt have asked for more.
'they were the best one ever, treated me like a
human being, absolutely lovely.'
'We had a say in everything. She always asked
what we want
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N19 Pilot Challenges?

• IT and computer systems
• Data protection restrictions
• Different working cultures across health and
  social care

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So what is next?
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Thank you
Any questions?