Facilitating new models of care within Integrated Community Services

Fragmented working across primary, community and social care leads to people with multiple illnesses or complex needs often receiving several visits or interventions from different providers. This results in poor patient experience and disjointed care.

This Southern Health NHS Foundation Trust project aimed to address these issues by integrating services within an extended primary care team and joining up primary, community and social care across the East New Forest.

It focused on four innovative projects:

• Two successful specialist lower limb wound clinics have been introduced, providing a high-quality, efficient service to patients who previously received wound care through home visits. Enablers included team visits to other successful wound clinics. Further clinics will now be introduced.
• An occupational therapy integration project has improved links between health and social care and reduced duplicate referrals. During a four-week pilot, 14 duplicate referrals were identified. Work is now underway to identify a new sustainable pathway. The initiative has led to cross-organisation barriers being lifted.
• A health coaching programme has been piloted, providing skills, knowledge and tools for staff to empower patients and facilitate self-management. Three out of four patients in the pilot showed a marked improvement in the management of their condition. The challenge now is to find the available time to implement the methodology in the clinical setting.
• The ‘Buurtzorg’ model is a nurse-led model of holistic care that allows teams to be responsible for the entire range of home care services. Planning work has taken place with the view to adopting the principles.  

Contact information

For more information about this project, please contact Rachael Marsh, Head of Nursing and Allied Health Professionals, Southern Health NHS Foundation Trust.