Joint working between health and social care – learning from social care providers

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Guys and St Thomas (GSTT) Transformation Team, Lambeth Council and CCG commissioners have been working together to help support and develop the commissioned community support (home care) providers.

Community health and social care teams are frequently supporting the same individual at home and should be able to contact each other easily in order to improve the service they are jointly providing.

The aspirations for care centred around service users’ needs, is often dependant on staff having the information and resources to enable them to work in a better way.

What was the problem?

Listening to the care providers at the regular provider forum meetings has enabled partners to develop a good understanding of the need for information and advice regarding common problems experienced by their service users such where to go to get advice on equipment and mobility aids and the availability of community health services and how to access them.  Not having this information can often lead to delays in the right care and support being provided.

What have we done?

Partners in Lambeth have co-designed a bespoke 16-page guide to community services for home care services.  This covers how to obtain help for common problems including:

  • Mobility/falls/ walking aids/wheelchairs
  • Equipment
  • Skin and pressure ulcers
  • Continence
  • Medicines
  • Foot care
  • Other specialist teams
  • Mental health care and wellbeing
  • Registering vulnerable adults with water and power suppliers

The guide also includes information to help structure communicating with a health professional using SBAR-D (Situation, Background, Assessment, Recommendation, Decision).

The guide can be printed in an A5 or A4 booklet and a short pocket guide and lanyard laminate are also available. It is hoped that this guide will be used by the teams to enable them to

  • Access appropriate help, advice and health assessment appropriately and rapidly
  • Reduce duplication of referral/ effort for the care providers
  • Help the care providers see themselves as a central and valued member of the community care team
  • Reduce inappropriate referrals received by health care teams
  • Reduce requests to GP’s to make referrals for services that can be accessed directly (Reduce GP workload)

What next?

The next steps include:

  • Co-designing a version for family and informal carers
  • Create a version for health care professionals
  • Undertake feasibility of incorporating into the digital directory of services

The transformation team are also working with the council and care providers to develop proposals and co-design resources for streamlining referral pathways and for education and training in relation to:

  • Falls prevention and management
  • Recognising and responding to deterioration in adults
  • Medicines management

For further information about this work or to see the guide please contact John.Egan@gstt.nhs.uk.

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