Integrated care case studies

Single team transforms Edward’s care

Blackburn resident Edward (not his real name) is one of the first people to benefit from health and social care professionals working together in the community.

Edward, who is in his 80s, suffered from swollen legs and a number of other health issues, which meant he had to see several health professionals including his GP, community matrons and district nurses.

The new integrated team in the East local area close to Edward’s home worked together to plan his care and they have also been able to link him into other services including adult social care.

Edward’s community matron oversees all his health and social care, meaning he can speak to one person who knows everything about the support and treatment he receives.

Edward says that having a system where organisations can talk to each other has really helped to sort his issues out, adding: “I was really down and just wanted some help, but between the community matron and my GP they got that sorted, so I have done really well in that respect.”

Community Matron Debbie Ainsworth

Edward was referred to our community respiratory service because he had contacted the GP surgery one morning to say that he was having difficulty breathing.

I think it became apparent that he had a combination of heart and lung problems and the heart problems were causing some other symptoms, such as his swollen legs.

But because we had that close working between ourselves the GP and district nurses we were all able to put our heads together and come up with a quick effective response to that.

This was an example of a new system working well and I think the primary change is around all care professionals involved with a patient having “virtual ward meetings”, leading to an increased sharing of information and prompt access to relevant teams and information.

There is more communication, there is more effective communication, it’s timely because it’s responsive there and then to the patient needs and I think hopefully it reduces duplication.

It means that through being prompt you can reduce those unplanned admissions to hospital and keep the patient where they want to be looked after.”

Dr Adam Black, Executive GP and Clinical Lead

 

Case study: Social worker Sue Crompton

Senior social worker Sue Crompton describes integrated care as an ‘exciting way of working’ which provides the best results for local residents.

Sue, who is a member of the Darwen locality team, attends weekly multi disciplinary team meetings and relishes the opportunity to share knowledge and experience with other professionals.

She explains: “It’s amazing the amount of people we have attending [the weekly meetings], with so much knowledge and experience that we can all tap in to and learn from.

“We always have had joint working with health and the third sector and charities but this is more organised and there are so many possibilities.

“It’s wonderful to be able to put names to faces and meet people and discuss cases and everyone has so much to offer. We will be discussing a case and we’ve got everyone there – occupational therapists, mental health specialists, district nurses, social workers, re-ablement, Age UK and community workers, so we can cover everything and really work together to get the best results for the citizens of Blackburn with Darwen.

“I am getting access to a better network of professionals and I then know who I can contact to find out any information or get any support I need. I can take cases that social services are involved with and put them to the other people there to find out what they can offer. That makes my job a lot easier, I don’t really have to go chasing people, they are there, and the ultimate beneficiary is the person we are caring for.

“Reablement is a pivotal service for social services and integrated care. The reablement team members support very vulnerable people, usually those coming out of hospital, and they are usually more involved with providing care than the social workers. They know that person better, so their input is really invaluable to the district nurses because then they know exactly what services the person is getting and we can discuss it and fine tune it and work out what’s best.

“We are not duplicating work and we are very much about a person-centred approach. We are talking about one person, their needs and how best this group can help that person and improve their quality of life, their health and their wellbeing.”

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