Integrated Community Support Teams (ICST)

East Kilbride and Strathaven

Lanarkshire

Where did we start from

• Stakeholder event – Tentative model

• Information sessions with staff

• Ongoing development sessions with staff and carers and stakeholders

INTEGRATED COMMUNITY SUPPORT TEAM

• ICST uses a township based, whole system approach to support the health and social care needs of older people. The twenty four hour, seven day service allows them to remain in their community setting, for as long as possible.

Integrated Community Support Team

LTC Team LeaderDistrict NursesCommunity Staff NurseClinical Support

WorkersPhysiotherapistsOccupational TherapistsAdmin & Clerical

Social Care Team Leader

Social Workers

Homecare Team Leader

Homecarers

Social Work OTs

Nursing AHPs

HomecareSocial Work

ICST

Carers3rd sector support

Specialist nurses

Specialist AHP’s

Community Mental Health

Other change fund projects

Falls TeamDischarge Hub

Rapid Response

Community Geriatrician

Pharmacy

GP

Bases

OVERNIGHT ICSTs 1&2 and HOMECARE

DISCHARGE HUB in HAIRMYRES HOSPITAL

ICST 2

GREENHILLS

HEALTH CENTRE

ICST 1

HUNTER

HEALTH CENTRE

GP caseloadPopulation=35,603

3,196>65yr2,536>75yr700>85yr

GP caseloadPopulation=31,808

3,447>65yr2,164>75yr670>85yr

Social work and Homecare

Civic Centre

PROCESSES

• Eligibility criteria• Referral process• Single Point of Access• Documentation• Info sharing – MIDIS and e-care viewer• Equipment• Supporting groups e.g LCG, RAG,

Practitioner Group, Lead Professional

SUCCESSES

• Motivation levels of existing staff

• Commitment to improve the experience of individuals using the service

• Continuity of nursing services

• Improved practitioner communication

• Staff feel they are offering much more for the person

• Single point of access

Successes

• Commitment from all disciplines and partners • Leadership and a robust consultation process• One nursing team 24/7 with additional co-

located Homecare overnight• Joint processes and procedures for Health and

Social Work• Greater respect and understanding of roles and

responsibilities; this has brought about a blurring of professional boundaries with integrated outcomes for the person/carer

Challenges

• Recruitment , new and changes• Accommodation Issues• Responsiveness/ flexibility of agencies• Cultural Change for Staff • Contractual changes for some staff• Size of teams• Agreement of processes within different

organisations

Challenges

• Changing traditions and cultures • Having one discipline manage multiple

professionals• Lack of co-located facility• Negotiating new interagency boundaries• Demonstrating the achievement of the set

strategic outcomes for the project against a backdrop of an ever changing political agenda

What do staff say

• They did not feel that there was enough representation from them at the planning stage.

• Some people found it difficult to adapt to the organic growth nature of the project

• They would have liked definite policies and procedures at the beginning

• All liked that they helped the project to grow, this was empowering

• Communication was much improved and speedier between disciplines

• There is now a sense of identity with ICST

What staff say continued

• The outcome for the individual and their carers/family is much better

• The use of other agencies such as the voluntary sector has improved

• The blurring of the professional boundaries continues to develop

• Their understanding of each others roles and responsibilities is far greater than before

• I.T. has to improve to enhance what is being delivered on the ground

• A joint management structure is the way to go