Knowledge Tree

Development and testing of a primary health and social care integrated team model in the comunity

Authors: Bob Brown, Western Health and Social Care Trust, GB, Anne Kilgallen, Western Health and Social Care Trust, GB, Ciaran Mullan, Western Health and Social Care Trust, GB

Northern Ireland has a long history across more than three decades of delivering integrated health and social care services in the community. Despite this, demand on hospital services continues to rise and there is limited evidence that hospital teams are shifting their work into the community for people with long-term conditions and complex care needs.The Western Health and Social Care Trust has developed a forward-thinking corporate strategy that includes the development of primary care based multidisciplinary teams located in GP practices, and focused on a collaboration of doctors, social workers, physical therapists, mental health workers and nurses, working together to better manage in particular people with long-term conditions and co-morbidities.This oral presentation or workshop will provide participants with an overview of the Trust’s strategic direction, the co-production approach undertaken to develop this in partnership with key stakeholders, and the health improvement as well as service sustainability outcomes we are measuring.We will present the early indicators of success, which includes, the work of a first contact physiotherapy practitioner, now working in a GP practice and assessing patients with musculo-skeletal conditions who would traditionally have been waiting to see a GP and often then a hospital consultant. The first contact physiotherapy practitioner is assessing, treating and reviewing patients in follow-up as required and achieving a significant reduction in the number of patients required to attend hospital.The presentation will also include a focus on other pathways that are integrating primary, community and hospital pathways and reducing demand on hospital care, including:- A pathfinder initiative to determine future health and social care services across a wide geographical area, using a whole system approach- An acute care at home service in the community- Older people assessment and liaison and frailty assessment and management service- Ambulatory pathways into the community from the hospital emergency department that prevent admission- Reducing the number of admissions to mental health hospital beds- The impact of an integrated community and hospital palliative care service, supported by the development of neighbourhood district nursing.The presentation will demonstrate how the Trust has organised itself to create primary, community and hospital care integration, is utilising continuous improvement methods to deliver measurable changes in practice and coordinating a quadruple aim approach to improve quality, financial sustainability, workforce development and population health improvement.

Keywords: integration, outcomes, collaboration, primary care, co-production

How to Cite: Zonneveld N, Miller R, Minkman M. Values and principles of person-centered integrated care: a systematic literature review (SIG meeting). International Journal of Integrated Care. 2017;17(5):A251

Published on 08 Aug 2019