The Rotherham Health Village pilot has resulted in fewer admissions to hospital compared with the Borough average.
The pilot began in July 2016 and is located at the Health Village which is the base for Clifton Medical Centre and St Ann’s Practice. The team consists of GPs, the community matron service, district nurses, therapists, a social worker, a community physician, social prescribing brokers and a community link worker. There is also dedicated mental health support and further links are being explored with the fire service, police, pharmacies and wider voluntary services.
The approach was developed to ensure that Rotherham health and social care services are able to continue to meet the needs of an ageing population with multiple health needs in a joined up way by working together.
The team proactively manages the care of their locality population by providing coordinated care closer to home, improving the experience of patients and their families and carers, helping to avoid hospital admissions, increasing independence, where possible, and aiming to improve mental health and well-being.
New technology solutions are critical to support the work. The Rotherham Health Record (RHR) allows them to track their patients’ journey through health services and plan their care accordingly. In the future social care and primary care colleagues will also have access to the Rotherham Health Record as well as their data being available within the system.
The key functions of the integrated pilot are:
• Early identification and prevention
• Reablement and rehabilitation
• Community engagement and development
• Case management and integrated assessment of need
• Parity of esteem; equal value given to mental health and physical health
Members of the team were asked what they believe are the main benefits of integrated working for them as team members:
‘Working alongside members from other services,’ ‘Knowing the patient if they come back around the system, ‘Link up with GP and LTC nurses,’ ‘information sharing,’ ‘joint visits,’ and ‘I have mostly valued the Community Link Worker role.’
The pilot is beginning to make links with the Integrated Rapid Response and Care Co-ordination Centre transformation initiatives and an external evaluation has just got underway. It is envisaged that the learning and next steps will be explored in early 2018.