Background; Weymouth and Portland Integrated Care Hub was started in November 2015, as a multiagency, co-designed project, aiming to support people who are frail, elderly or have complex needs. The 'hub', based in Westhaven Community Hospital, collocates duty workers and administrators from the locality's physical health, mental health, social care, ambulance services and third sector teams.
Key features; No significant additional investment – reconfiguration of existing community services
Local single point of access - reverting to Countywide SPOA overnight
Admission avoidance and supported hospital discharge
'No hand offs'
Systm One IT module for integrated referral management and information sharing to local teams, including primary care
Three Health and Social Care Coordinator posts, working over 7 days
Step up community beds
Acheivements - one year on;
The hub, very quickly moved from being a brave trial to a mainstream, sustainable and successful way of working. The team are working with people who have high and very high levels of frailty.
Excellent patient and informal care giver feedback, gathered through semi structured interviews
Reduction in acute bed days and ED admissions for over 65s
Stabilisation of emergency admissions for locality against a predicted increase
High referrer satisfaction - 'I make one call and things just get sorted'
Staff are now seeing themselves as 'one team' and putting the patient at the centre of everything that they are doing.
The hub is a factor in staff recruitment in the area.
50% step up use of community hospital beds - a community bed is now always available as an alternative to acute admission.
Model being used as a blueprint to roll out to all other localities in Dorset
Barriers to change:
Key barriers that have needed to be overcome are;
Working across different organisations with differing priorities/objectives
Culture change for staff - 'one team' approach
Trail blazer - creating and selling a vision
Existing management structures are becoming a barrier to progress
Insufficient data to fully evaluate work
Future plans and next steps: Although Weymouth and Portland Integrated Care Hub is proving to be a successful model, advances are already being made.
A proactive element to hub working - risk profiling, MDT meetings, and advance care planning and follow up for those referred in crisis to reduce the likelihood of deterioration in the future.
Integrated working with Dorset County Hospital's acute hospital at home
Consideration of rising frailty and patient activation/community support
Can all community referrals be managed through the hub?
Review of management structures to consider a full locality integrated team.
Conclusions: Weymouth and Portland Integrated Care Hub was formed just over a year ago as a multiagency project, which has, with little additional cost, transformed the service provided to local people who are frail, elderly, and have complex needs. The learning from this project is being rolled out to all other localities in Dorset, and also used to make key developments that will improve the service provided going forwards.