What is the challenge your project is going to address and how does it connect to your chosen theme?

Different aspects of a persons health and well being are currently considered and delivered in isolation, very often patients are inundated with health and social care personnel without a joined up prioritised plan.  This project will bring together all aspects of health & social care to provide holistic care.  We want to utilise our improvement capacity beyond Queen Elizabeth hospital to incorporate transformation in primary & secondary care, social services, community services, palliative care and social care needs, facilitating professionals having access to shared infrastructure & processes to allow joint care planning, co-ordination and access to specialist advice.

What does your project aim to achieve?

By setting up fortnightly MDT in 5 localities we aim to :

Allow priorities, actions and interventions to be identified holistically so no part of a person health and well being is considered in isolation

Give patients access to a wide range of health and social care support e.g. therapy, intervention, long term social care, specialist palliative care, rapid response social care and social prescribing.

Support cross organisational professional learning and development across disciplines and clinical teams.

Improve coordination of care, reducing inefficiencies in the current system re: hand-offs and duplication.

We need funding support for: Improvement administrative support, outcomes monitoring and technological development.

How will the project be delivered?

Full range of professionals to meet weekly in GP Practice to discuss complex patients and agree the course of action, and produce a joint care plan.  Resolving issues and working through a prioritised plan.  The MDT should allow professionals to learn from each other, give and receive advice and jointly sign up to a share care plan.

The main risk is engagement and back fill from  all parties.

In the pilot we have seen a reduction in A&E attendances, reduction in NEL admissions, reduction in unscheduled contacts from the rapid response teams.

What and how is your project going to share learning throughout?

Professional Development:

Valuable learning sharing the MDT approach, expanding awareness of the roles of other professionals, feeling more ‘networked’ with colleagues, and improving knowledge across health and social care as well as managing complex patients in a supportive environment.

Improved Outcomes:

Patient feedback to structured care.

Help improve the management & coordination of person centred care, whilst streamlining referrals and managing demand.

Shared learning from this will be presented internally through out the 5 localities and via the Gateshead System group and with our Q colleagues in the Q community.