First neighbourhood team co-located

Professionals from the first integrated neighbourhood team to be co-located say it is already enabling them to deliver better services for the people of Stockport.

Eight integrated neighbourhood teams of health, social care and voluntary sector professionals have been established across Stockport as part of the Stockport Together transformation programme.

This is already improving the way professionals communicate and deliver joined up care for patients, through regular triage meetings between health and social care professionals and GP-led MDTs, focussing on the most complex patients. However, the objective has always been to work towards co-locating the teams together permanently in the same buildings.

The Victoria team is the first to be co-located, with social care, district nursing, and TPA (Targeted Prevention Alliance) voluntary sector staff now all based in an open plan space at Stopford House. The TPA includes Age Concern, Flag, NACRO, Relate, Stockport Homes, and Threshold.

Kathy O’Hagan, Staff Nurse within the Victoria District Nursing service, said: “It’s been brilliant, all I have to do is speak to the person opposite me and I can get some information about our patients that helps us to sort out their care. The social workers are asking us for information as well.

“So for example yesterday, I’d been out to see a patient and the social workers went out later, noticed something was wrong, and asked us to go back whereas we would usually go back next week so it’s been brilliant. We all get on really well together as well.

“It’s already producing benefits, like causes for concern. And it’s not that we’ll phone a hotline number, we’ll actually speak directly. Sometimes if you speak to a social worker, they are the social worker of that actual patient you’ve seen. Everyone has their own caseload but they also have access to other service users as well so it’s really good.”

Jan Krynski, Social Worker with the Victoria team, said: “It’s a lot easier being face to face with District Nurses because instead of having to leave messages and wait for people to get back to you, you can just speak to somebody about the problem. You can have conversations about things like leg ulcers and catheter care and so on and any problems service users have.

“If you go on a visit and find there’s an issue with nursing care then you can speak to a District Nurse and get some quick action rather than waiting for a referral to go through. It’s also much easier with the TPA being in the same room rather than leaving phone messages and emails, and doing joint visits is definitely a good way forward. I definitely think integration is a really good idea.”

Claire Watts is one of the new Social Care Officers introduced to the neighbourhood teams to support social workers, freeing up their time for the more complex cases.

Claire agrees that co-location is already benefiting people on her case load. “I’ve had a few clients where we needed to check if there is any District Nursing input and I can now literally just stand up and the bank of nurses facing me and they can check. If there’s something that comes up with a medical term I don’t understand as it’s abbreviated, it’s really useful to have them there.

“They approach us as well and ask if this person is known to the services so it’s a good way of sharing information. Also, the TPA is a good team to work with as they can do a lot of the practical groundwork with people.”

Siobhan Myers, Senior Keyworker for the TPA (Targeted Prevention Alliance), said: “We’re already seeing massive benefits for the people we’re working with because of improved efficiency. Before, we would email a social worker, they would try to call us, and often we’d miss them. Now a TPA worker can simply walk across to the Social Worker or District Nurse and discuss a case.

“At weekly triage meetings, Sonia (District Nurse Lead), Kirsty (Social Work Manager), Nicky (Advanced Nurse Practitioner) and I discuss new cases and can plan the best course of action. This has resulted in a more responsive and robust approach to new and current cases.”

Siobhan shared one recent example case where an older person’s medical needs were met but they were socially isolated.

“I was able to get our Community Connector out to this person the same week without the need for referral forms & phone-calls. Similarly, UTIs are one of the main reasons for hospital admissions in Victoria if we are worried a person may have a UTI, Nicky will visit them often the same day and test for a UTI. She will then organise any necessary prescriptions the same day.

“Although Victoria’s integrated team is very new, we are very optimistic that the journey for people accessing Health & Social Care will improve and that the co-location of teams will prevent unnecessary hospital admissions.”

To find out more about Nicky Makepeace’s work as an Advanced Nurse Practitioner, see this article.

Work continues to co-locate the other neighbourhood teams and updates will be shared as the work progresses.

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