Joint working in community teams has developed across Scotland and across a range of care groups over a number of years. This workshop shares the learning from an award winning integrated team and explore some of the key, common messages for practice. It highlights challenges in developing the workforce, mainstreaming the approach and spreading this to other localities. The team outlines examples of successful outcomes in the context of health and social care integration. Contributed by: Joint Improvement Team & South Lanarkshire Partnership

1. Integrated Community
Support Teams (ICST)
East Kilbride and Strathaven
Lanarkshire

2. Where did we start from
• Stakeholder event – Tentative model
• Information sessions with staff
• Ongoing development sessions with staff
and carers and stakeholders

3. INTEGRATED COMMUNITY
SUPPORT TEAM
• ICST uses a township based, whole
system approach to support the health and
social care needs of older people. The
twenty four hour, seven day service allows
them to remain in their community setting,
for as long as possible.

4. Integrated Community Support
Team
LTC Team Leader
District Nurses
Community Staff Nurse
Clinical Support
Workers
Physiotherapists
Occupational Therapists
Admin & Clerical
Social Care Team
Leader
Social Workers
Homecare Team Leader
Homecarers
Social Work OTs

5. Carers
3rd sector
support
Specialist
nurses
Specialist
AHP’s
Community
Mental Health
Other change
fund projects
Falls TeamDischarge
Hub
Rapid
Response
Community
Geriatrician
Pharmacy
GP

6. Bases
OVERNIGHT ICSTs 1&2 and HOMECARE
DISCHARGE HUB in HAIRMYRES HOSPITAL
ICST 2
GREENHILLS
HEALTH CENTRE
ICST 1
HUNTER
HEALTH CENTRE
GP caseload
Population=35,603
3,196>65yr
2,536>75yr
700>85yr
GP caseload
Population=31,808
3,447>65yr
2,164>75yr
670>85yr
Social
work and
Homecare
Civic
Centre

7. PROCESSES
• Eligibility criteria
• Referral process
• Single Point of Access
• Documentation
• Info sharing – MIDIS and e-care viewer
• Equipment
• Supporting groups e.g LCG, RAG,
Practitioner Group, Lead Professional

8. SUCCESSES
• Motivation levels of existing staff
• Commitment to improve the experience of
individuals using the service
• Continuity of nursing services
• Improved practitioner communication
• Staff feel they are offering much more for
the person
• Single point of access

9. Successes
• Commitment from all disciplines and partners
• Leadership and a robust consultation process
• One nursing team 24/7 with additional co-
located Homecare overnight
• Joint processes and procedures for Health and
Social Work
• Greater respect and understanding of roles and
responsibilities; this has brought about a blurring
of professional boundaries with integrated
outcomes for the person/carer

10. Challenges
• Recruitment , new and changes
• Accommodation Issues
• Responsiveness/ flexibility of agencies
• Cultural Change for Staff
• Contractual changes for some staff
• Size of teams
• Agreement of processes within different
organisations

11. Challenges
• Changing traditions and cultures
• Having one discipline manage multiple
professionals
• Lack of co-located facility
• Negotiating new interagency boundaries
• Demonstrating the achievement of the set
strategic outcomes for the project against
a backdrop of an ever changing political
agenda

12. What do staff say
• They did not feel that there was enough representation
from them at the planning stage.
• Some people found it difficult to adapt to the organic
growth nature of the project
• They would have liked definite policies and procedures
at the beginning
• All liked that they helped the project to grow, this was
empowering
• Communication was much improved and speedier
between disciplines
• There is now a sense of identity with ICST

13. What staff say continued
• The outcome for the individual and their carers/family is
much better
• The use of other agencies such as the voluntary sector
has improved
• The blurring of the professional boundaries continues to
develop
• Their understanding of each others roles and
responsibilities is far greater than before
• I.T. has to improve to enhance what is being delivered on
the ground
• A joint management structure is the way to go