What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

Multiagency, multidisciplinary care is necessary to meet holistic care needs of individuals, particularly those living with long term health conditions.

Multidisciplinary teams are well established in many communities. Local experience has demonstrated effectiveness of these multiagency teams, and has highlighted the potential of integrated working.

The challenge experienced by systems, teams and patients is to unlock the value of integrated approaches to care, both in terms of clinical effectiveness and productivity for teams.

Strong professional identity, organisational culture and management of risk are well recognised challenges in integrated teams. Whilst co-location, co-delivery of care and effective processes and procedures are pre-requisites for effective multiagency working, they are not the sole ingredients that create the magic that true integration can deliver.

Our ambition is to develop our local model from a strong foundation, to maximise the impact to patients, carers and system, through the shared development of staff.

What does your project aim to achieve?

Integrating services (structurally or functionally) is challenging, and requires complex interventions.

Our aims for this project:

• Enhance cross-organisational joint working by testing development of Neighbourhood Huddle Teams to build stronger relationships between community health and primary care services
• Continue to refine functions and roles and clarifying processes to ensure consistency in practice across MDTs
• Introduce an MDT learning framework, to improve skills and capabilities relating to multidisciplinary work, frailty and leadership skills in these domains, including the use of simulation training.
• Develop a coordination function supporting MDT delivery, and embed systemic support for proactive care cohorts, including residents with long term conditions experiencing health inequalities
• Embed reflective practice, quality reviews, and supportive supervision in multiagency delivery functions developing a culture of continuous improvement.
• Develop quality measures/frameworks relating to staff and resident experience, team integration, MDT effectiveness and safety.

How will the project be delivered?

We envisage they would work with the internal team including Integrated Community Network (ICN+) champions group to meet the project’s objectives.

In the past 2 years ICN+ adopted a ‘test and learn’ approach to delivery of change, to support MDT operations and underpin model development. The project will allow the team to accelerate the change activities by enhancing the capacity and capabilities of existing operational and project team to support all colleagues involved in engagements, learning and feedback gathering.

We would utilise existing structures and partnerships including full support from the Integrated Management Team (IMT) providing operational oversight to existing multidisciplinary team (MDT) operations and performance.

How is your project going to share learning?

Throughout the project we would document learnings and report on progress, with an evaluation report created and available to be shared across the QI community. We will also be happy to be approached for any follow up conversations about any specific aspects of the project as well as wider ICN+ programme.

We anticipate the creation of resources that can be shared to other regions that support the development and training of teams working in integrated neighbourhood services, as well as resources to measure and monitor the effectiveness and clinical quality of such approaches.

As part of the project, qualitative feedback will be sought from MDTs alongside existing or new MDT service performance metrics to allow us to monitor and learn as we progress. We would be sharing learnings through existing local and regional forums to maintain support and engagement levels and exchange knowledge.