Integrated care programme

This project will develop an integrated team approach to carry out the hospital discharge process with a focus on the discharge to assess (D2A) model. This will improve the experience for patients, speed up discharges avoiding delays and streamline processes reducing duplication.

The Urgent Community Response project has been looking at ways to joining up the multiple crisis response services currently operating independently of each other by developing a single urgent care service (UCR) for County Durham.

By doing this we’ll be able to align and coordinate all out of hospital urgent care, not by creating a new service or provider, but by developing a specific integrated service and with dedicated leadership. This means improving our ability to treat people in their homes and stopping wherever possible crisis becoming an admission to either A&E or hospital.

Through the integrated UCR teams, older people and adults with complex health needs who urgently need care, can get fast access to a range of health and social care professionals within two hours. This means quicker assessment and treatment, with care in people’s homes or place of residence, avoiding unnecessary hospital admissions and reducing the stress and anxiety this can cause. And when a hospital admission is unavoidable, the service will help people return home from hospital who need extra support. 

The next phase the project will work closely with the non NHS providers of urgent response across County Durham to look at ways to align these separate pathways and bring services closer together in a truly unified service. Part of this work
will be to develop a single referral point for all urgent care needs in County Durham.

The Quality Project aims to develop a single coordinated approach to quality and safety measuring, monitoring and assurance across health and social care in  County Durham. This highlights the  importance of the Partnership working together operationally to champion and drive improvements in quality across our services.

Early engagement work across three workshops with colleagues from commissioning organisations in County Durham has helped to build an understanding of what quality means to those working within different parts of the Partnership.

As part of the Occupational Therapies project, OTs from the NHS and local authority have been working collaboratively to look at ways to streamline their services, particularly where there’s duplication.

In this project we are looking at ways to develop an integrated provision of a single telephone service for all calls relating to community nursing and social care for the general public as well as professional enquiries and crisis calls.

The service is currently delivered through a single telephone line which is answered by an automated system with calls diverted to either community health operatives (NHS) or Social Care Direct (DCC).

Here we are looking at how effective our current Teams around the Patient model for co-location and collaboration across community health and social service is operating .

There are currently 13 TAPs of community aligned staff covering 69 GP Practices across County Durham. These TAPs are grouped together to provide ‘wrap around’ care to populations of between 30-50,000 patients through a multi-disciplinary working platform involving community nursing, social workers, GP’s and allied health professionals.

This project is looking at ways to integrate and streamline the various home visiting schemes currently operating across County Durham to support admission avoidance into a single service, seven days a week. This will improve pathways between Primary and Secondary Care and other system partners such as GP extended hubs and NHS 111. This approach will develop a more integrated approach to patient care and join up services across the area.

This project will consider how well integrated and effective the care being provided in care homes is. The workstream will undertake a comprehensive baseline assessment of current achievements against contractual and framework requirements with a view to enhancing the current integrated approach.