Care closer to home: integration and Neighbourhood Teams

There are currently 13 Neighbourhood Teams up and running covering the whole of the county. These are teams of GPs, nurses, social workers, mental health practitioners and therapists working together with others in the community (such as home care, the voluntary sector and housing services) to provide a coordinated and effective service for some of our most vulnerable residents. 

Quote5The teams have been developed as a direct response to both staff and the public who recognise that care can sometimes be fragmented, with residents being passed from professional to professional and having to wait a long time for appropriate support.   We know that if we join up services in the community then patients get quicker access to the right support and crucially, we can keep our older patients out of hospital.

What does this mean to patients?

Family A live on the east coast and own their own home.  Mr A is diabetic, Mrs A has a tumour, depression and self harms; they have a 13 year old daughter.  Mrs A is nervous and doesn’t cope well with strangers, when Mr A is at work their daughter stays at home to look after their mother.  The family are socially isolated.Story1.jpg

Before Christmas Mr A went to the Wellbeing Service to get help for their leaking roof.  The Wellbeing Service found that there was a section of the roof missing, no electricity or heating and limited cooking and bathing facilities – the home was deemed unfit to live in.

The Wellbeing Service brought the case to the Neighbourhood Team meeting involving the GP, mental health practitioner, adult social care, parish nurse, Age UK, Ward sister and community nurse.  The Wellbeing set up a team around the child to support the family and assigned a homeless officer to them.  Emergency accommodation was found and the family moved before Christmas.  The parish nurse offered a befriending service and an invitation to a parish Christmas lunch, as well as Christmas hampers.  Adult Social Care will provide ongoing support to the family.  Age UK offered financial advice, including how to access benefits.

More information on our Neighbourhood Teams is available here.