Community Integrated Teams and Community MDTs

Five multi-disciplinary Community Integrated Teams (CITs) are now in place to provide effective, high quality and co-ordinated care to people with the most complex needs in their own home, keeping them as independent as possible and out of hospital if they don’t need to be there.

Based in key localities in the city – Bunny Hill, Downhill; Hendon; Houghton; Grindon and Washington – the teams are made up of core staff teams including district nurses; community matrons; social workers; living well link workers and carers support workers.

By working from a single, shared base, staff are able to work directly together, not only improving communication; but avoiding duplication and speeding up response times for local people.

Around this core team a wide range of other professionals link in to a wider, locality-based ‘network’ to ensure people get the right care from the right organisation or specialist.

The network includes GPs and practice teams; community physiatrist nurses; community pharmacists; care homes nurses and palliative care nurses, and is growing as relevant organisations or individuals are identified.

MDTs

A key part of community-care integration is the development of multi-disciplinary teams (MDTs) centred on each GP practice in the city and linked to their relevant local CIT. Patients identified as needing extra support by each practice may be subject to an MDT meeting where a range of professionals (including CIT members) discuss; plan and implement an co-ordinated care plan which encompasses a full range of services depending the person’s need.

While the GP leads clinical decision-making through MDTs they can call on a much wider support from the full network to cater for a patients; health; social and emotional care.

Meetings are managed by MDT co-ordinators and tailored to each practice population’s specific needs.