Integrated working-Integrated Neighbourhood Teams &

Neighbourhood Networks

Nic Roper, Area Manager- Suffolk County Council

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What’s the background?

• Long standing knowledge that integrated care will provide a better health and care system for people – but in East and West Suffolk partners were struggling to make this a reality at scale

• The Health and Care Review – started in December 2012 - aimed to create a shared view of a future integrated system

• The vision and service model has been signed up to by all partners, and has informed the Suffolk Better Care Fund Plan

• Partners are now committed to delivering the new model of care – Connect Sudbury and Connect East Ipswich are the forerunners for the new system

• 2 main building blocks for integrated working in Suffolk: Neighbourhood Networks & Integrated Neighbourhood Teams

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Neighbours

Employment

Friends

Family

Church

Local Services

Local Shops

Community Groups

Integrated Neighbourhood

Team (INT) – multi agency

team

GP

Clubs

The Neighbourhood Network: a person’s support network

Schools

Supporting the individual to remain healthy, active and engaged in their community

Local Shops

Integrated Neighbourhood

Team (INT) – multi agency

team

GP

Neighbourhood Network aspirations

• Information- Good clear, easily accessible local information, supporting independence, self reliance, confidence and self-care

• Connectedness - Easy or supported access for individuals to connect with others. Good knowledge within organisations about others

• Age and disability friendly communities- Accessibility to employment, services and leisure opportunities etc

• Voluntary and Community Sectors- Thriving, supportive alliances of local voluntary sector organisations. Well known and well used local groups and activities

• Behaviours- No wrong door; widely adopted strengths-based approach; warm handovers; respect between people and organisations within a person’s Neighbourhood Network and statutory services for knowledge and skills held

Developing community capacity- what’s already happening?

• Local networking events

• Dementia Friendly Communities

• New Infolink website: http://infolink.suffolk.gov.uk/kb5/suffolk/infolink/home.page

• Voluntary and Community Sector scoping

• Introduction of Local Area Coordination

• Community pharmacies

• Community Safety

• Health and Wellbeing Board and voluntary sector partners’ campaign to reduce social isolation and loneliness across the age range

Neighbours

Employment

Friends

Family

Church

Local Services

Local Shops

Community Groups

GP

Clubs

The Neighbourhood Network & the Integrated Neighbourhood Team

Schools

The Integrated Neighbourhood Team

ACS

Suffolk Community Health Home First

GP Primary care

Local Area Co-ordinator VCS

Mental Health

District/ Borough Council

Housing Interface Geriatrician

CYP

Police

Getting to know each other:• INT Directory• Workplace shadowing• Life Timeline tool• INT Toolkit

The Community Health & ACS Social Care part of the team

Home First

GP

Primary care

Local Area Co-ordinator

VCS

Mental Health

District/ Borough Council

Housing

Interface Geriatrician

CYP

Police

ACS/ Suffolk Community Health

Key deliverables for Health & ACS:• Tight integrated partnership which is co-located with shared processes, changing business as usual • IT pilot but also interim tactical solutions for joint assessments, single plans, single view/

accountable worker• Generic skill bases• Operational Manual

Creating opportunities for wider integrated working-an Enhanced Health & ACS MDT….

MDT Co-ordinator

GP

SW

District Nurse

Community MatronOT

Physio

Mental Health Link Worker

Practice Staff

VCS

CYP

Police

Local Area Co-Ordinator

Home First

Housing

District/ Borough Council

Creating enhanced MDTs:• Learning from the best• Effective Risk Satisfaction/ case

finding

… possible other wider Enhanced MDTs

MDT Co-ordinator

GP

SW

District Nurse

Community MatronOT

Physio

Mental Health Link Worker

Practice Staff

Learning from the ACS & Health Enhanced MDT• Hot desking opportunities• Co-location opportunities• Integrated Learning Sessions• Data sharing protocols

Police

Mental Health

ACS

Ambulance Service

CCG

ACS

GPs

Health & ACS MDTHigh demand families Care Homes

GP Practice 1

GP Practice 2

Health & Social Care integration

Wider multi agency integration

Phased implementation

GP Practice 3

GP Practice 4

GP Practice 5

• INT Directory

• Workplace shadowing

• Operational manual

• INT Toolkit• Co-location• Hot desking• Learning

sessions• IT pilot• MDTs