Workstream Case Studies and Factsheets

Community Integrated Team Networks Case Study - June 2017

Community Integrated Team Networks Case Study – June 2017

As each of the five Community Integrated Teams (CIT) became more established, and the work within the Multi Disciplinary Teams drew in more teams and services, the definition of a single ‘team’ didn’t reflect the ever increasing scope of the work being undertaken.

Services including those provided by pharmacy, mental health, palliative care nurses, practice nurses and managers, which are not co-located with the community nurses and social care staff, but vital to the work, needed re-defining.

Multi-disciplinary teams Case Study - June 2017

Multi-disciplinary teams Case Study – June 2017

Integrated working is a critical part of the All Together Better Sunderland vanguard new care model and in October 2015 Multi-disciplinary teams (MDTs) were introduced as a key part of the delivering truly joined-up care across Sunderland via practices and the wider Community Integrated Teams.

Risk Stratification and Multi-Disciplinary Team (MDT) Meetings Case Study - July 2017

Risk Stratification and Multi-Disciplinary Team (MDT) Meetings Case Study – July 2017

The All Together Better Sunderland care model aims to reduce the likelihood of people going to hospital, either as an emergency or as an avoidable admission primarily by bringing together a range of communitybased health, social care and community/voluntary providers.
Community Integrated Teams Case Study - July 2017

Community Integrated Teams Case Study – July 2017

Community health teams and social care staff within Sunderland previously worked separately, with some collaboration, but still within their clearly defined roles on either side of the care divide.
Care Home Alignment Case Study July 2017
Care Home Alignment Case Study – July 2017

The concept of care home alignment was introduced to Archers Park Care Home by Sunderland GP Alliance. Prior to this, 40 residents were cared for by 15 different GP practices from across the city.

This presented major difficulties, with each practice, for example, using its own channels of communication; their own process for repeat prescriptions or how they arranged examinations and appointments for our residents was a logistical challenge.

It was both time consuming and confusing for Care Home staff and meant GPs could be travelling from different areas of the city to see just one patient.