The text below is taken from a case study on the national NHS Futures website. Team Up Derbyshire has been held up as best practice nationally for its work in progressing integrated care. As the NHS Futures website is password protected, we are reproducing the article here for those unable to access that site.
Profile
Key attributes:
Derbyshire’s population is expected to increase by 100,000 by 2043 and the population aged 90 and over will more than double in this time frame.
30,000 people are living with moderate or severe frailty.
There is a marked difference between Derby and Derbyshire in terms of ethnic mix, with only 4% ethnic minority population in Derbyshire compared to 27.2% in Derby city
There are 18 areas in Derbyshire which rank amongst the 10% most deprived areas in England.
Summary
Team Up Derbyshire was created in 2021 to support people who are housebound, extremely frail or in care homes. Team Up Derbyshire includes the national Ageing Well Programme, (Enhanced Health in Care Homes, Urgent Community Response, Proactive Care) plus Falls recovery and Home Visiting Services at scale.
The programme develops Integrated Neighbourhood Teams by bringing existing services together so that people who need support into their own home (even if this is a care home) can be seen by a multi-professional team more efficiently, without duplication and placing the patient at the heart of their care.
A key enabler of working together is the multi-disciplinary team meetings which meet regularly to discuss a case list of patients.
The range of partners include the Primary Care Networks, Derbyshire Community Health Services, Derbyshire County Council, Derby City Council, Care Homes and the voluntary and community sector.
Headlines of the service:
95% of staff recommending the service
93% recommending the service as a place to work
For the over 65 population compared to the previous 12 months from March:
The Home Visiting team has made 24,259 visits
There has been a reduction of 2,367 EMAS cat 3 responses
There has been a 1,467 reduction of those with a length of stay of 1 & 2 days
6,982 people needing a 2-hour UCR rapid nursing and therapy response have been seen
Aim of Team Up Derbyshire
Every year it costs £100 million to look after people in Derbyshire living with moderate or severe frailty.
People who are living with moderate or severe frailty required 96,605 hospital bed days (in 2019-20 in Derbyshire alone) – the equivalent of about 10 wards. This figure is only predicted to increase in the future. The aim of Team up Derbyshire was to create one team across health and social care to see all people in a neighbourhood currently unable to leave home without support. The team wanted to create more capacity without creating a new service bringing together all health and social care partners across the system.
They aimed to:
Promote a team approach across the ICS to looking after people with frailty to support people at home for longer.
Ensure the care and support people receive is based on their wishes.
Offer support for their family members.
Develop more rapid community response teams.
Offer more NHS support in care homes
What we did and why
The team was developed to prevent people needing to go into hospital where possible. It provides both preventative care – anticipating health problems before they occur – and reactive/urgent care as and when required.
The team also brings together a range of services already doing this work to make the response more streamlined. This includes:
Acute home visiting service – continuity and support to release pressure on GPs
Urgent community response service - crisis response care within two hours of referral and reablement care within two days of referral.
Enhanced health in care homes
Anticipatory care
Step up and discharge pathways
The team conduct the visits, using Personalised Care and Support Planning and Respect forms for all housebound patients.
Issues being addressed
The team addresses a wide range of issues for people with frailty including any immediate or long term physical and mental health problems, social care problems.
It also connects people with third sector organisations issues which could be impacting their health sector such as:
debt management
housing problems
help with shopping
putting people in touch with local groups to reduce isolation and loneliness.
Structure
The PCNs regularly hold multi-disciplinary team meetings which include attendance from care coordinators, mental health, social care, Advanced Care Practitioners, GPs, and other stakeholders relevant to the people being discussed.
The team then provides coordination and oversight to achieve common agreed outcomes for the patients known to the service or in need of the service.
Patients who have recently been discharged from hospital also receive a follow up call within 1-2 days to pick up any early concerns. These concerns are then address by the most appropriate people in the team.
Care coordinators will often act as the central point for the patient management plans, proactively sharing information across the team. This can be accessed by patients/family or carers and professionals.
MOUs are in place which outlines roles and responsibilities, governance, and flow of reporting systems for staff (e.g., sickness absences).
Partners involved in the INT
The team is coordinated by the PCN and is made up of people employed by different organisations coming together for a shared purpose i.e., additional staff who deliver services are not all employed by the PCN, some are sub-contracted from other local service providers which include local authority, voluntary sector, and wider community organisations.
These include:
PCNs
Derbyshire community services
Derbyshire County Council
Derby City Council
DHU
Evaluation
Evaluation of the programme is undertaken in several ways:
Data collection by the Home Visiting Services
Data collection as part of the UCR NHSE target monitoring and community services dataset collection
The use of an Ageing Well dashboard which was developed for the programme
Surveys sent out to staff and users of the service
Work in progress regarding evaluation of integration
Local residents have also been engaged with in the programme, right at the start as a webinar (during covid lock down) and subsequently as part of the Citizens’ Panel.
Learning
Ensure roll out of learning - training is shared for new staff joining the team, accessed from across the three organisations as appropriate.
Ensure visibility of current management plans across the team and their coordination using shared records or a central point.
Ensure access to patient level information across the system - all main providers use the same electronic medical record system.
An investment in time is needed to see the long-term results
The importance of data to show the difference that is being made and the need to invest in this
Challenges
Delivering transformative change during the COVID crisis
Delivering services that have the patients at the forefront while still being mindful of NHSE targets
Bringing all stakeholders together to make changes when operationally teams are stretched
Workforce – availability of key groups of staff has slowed down recruitment and delivery of services
The early development of PCN's has meant that they are developing at the same time as change is required
The need for clinical systems to work across the system as a requirement for change
The lack of joined up thinking regarding estates and the need for co-location of teams
Patient and professional quotes
Quotes from patient families:
I'm convinced that the attention and care provided by the Team has meant my Uncle B has recovered
I just want to congratulate you on an excellent department within the NHS. My Father is 96, and requires quite a lot of care now still living alone in his own home, (where he wants to be)
Thank you for making my mum so comfortable last week. The last days of her 98 years were filled with compassion and respect. She & I couldn’t of asked for more
Quotes from staff:
It allows people to stay in their own homes, in familiar surroundings near family/friends and it stops filling up hospitals so allowing more urgent care to happen in hospitals or allow space for elective care”
Avoid unnecessary admissions to patients who are better off at home”
Facilitation of timely discharges, smooth transition from hospital to home, support to carers/ family members
Next steps
Team Up Derbyshire/Ageing Well aims to invest up to £13 million in 2023-24 in the development of these integrated community teams across the system. This investment will continue to be made to enable the work to be supported ensuring that services integrate and that high quality services are available for patients.