creating a vision for multidisciplinary working

SCoping workshop findings

1. Building the forres ‘brand’

Building the Forres ‘brand’ and identity was discussed as a way to support multidisciplinary working and public conversations around care expectations. The group talked about the need to promote realistic expectations with the public potentially through an awareness campaign. Promoting expectations and awareness would also enable people and families to know who to speak to but also not ‘worry’ about who to speak to in terms of getting appropriate information or signposting. In addition, aspirations around developing the leadership and best practice of the multidisciplinary team would lead to Forres becoming known for ‘leading the way in Health and Living Well promotion’.

2. Coordination and streamlining

The group highlighted the need for clarification around the current ‘Access team’ regarding pathways and generating better links between the access team and professionals. Considering an access team equivalent in Forres was also suggested and described as a central core of people that could communicate with the wider team. Having this central team would enable a single point of referral, streamline referral pathways and provide infrastructure to ensure that there are not too many steps to receiving the appropriate care.

In relation to supporting streamlined pathways and referrals to appropriate care, the group discussed the idea of a nucleus of health professionals with Forres becoming a ‘hub’. The development of a specialist rapid response team (‘Care ninjas’) was described as a way to enable proactive, responsive care that could address crisis situations and potentially avoid emergency hospital admission. The group also discussed the possibility of a team who could provide advice and assessment, again referring or directing towards more appropriate services and a personalised care pathway. This means that the resulting system needs to balance both crisis and prevention to ensure a responsive approach. Providing infrastructure to address ‘4.30pm on a Friday’ phone calls was also highlighted.

Building these team responses to care needs and developing a more coordinated approach requires a balance of recognising professional identities whilst also ‘not being precious about what you do’. However, it was highlighted that there is also the need to acknowledge that providing a responsive environment is resource dependent.

3. Enabling Multidisciplinary working through technology and resources

The ability for seamless communication was highlighted as key to ensure people can work in a cohesive way. Although staff are co-located it is about enabling time to have conversations and to ensure these are with the most appropriate person. Reinstating weekly multidisciplinary meetings (with VC supporting people to join virtually) and structured action meetings to enable a planned approach to care were both suggested. The group highlighted the need for IT systems to integrate to allow information sharing and make communication as easy as possible. Improved IT systems for documentation was also discussed to be time valuable and structured.

The group also suggested having a local store for equipment in relation to Occupational Therapy that would allow resources to be accessed and deployed, as well as the opportunity to teach patients how to work with equipment.

In addition, exploring multidisciplinary working in the context of the virtual ward model was also discussed. The virtual ward allows prioritisation of patients who require professional input and therefore could support a multidisciplinary approach through coordinating the team around the person.

4. Local assets: opportunities for integration

A number of local assets were identified who provide local resource and support such as the local Care Homes (supporting ACPs, CPR decisions, ward rounds, commissioned beds, increased community nursing service), Cameron Court (day service, respite and residential care), RAFA (emotional, financial and physical support), FACT (catalogue of local voluntary services, befriending service, Cameron project), Community Centre (activities for young adults, BALL group), Health Promotion team Moray (tea parties, health education) and Quarriers (based in Elgin).

The group identified a number of opportunities to integrate assets in the local community in terms of service provision for key psychosocial support. One idea was around support from informal carers to give advice about Power of Attorney. A voluntary enablers group who could be given training to support reablement was also suggested. It was noted that this would be in a voluntary capacity and therefore would have to ensure the role didn’t do anything beyond what would then be considered a professional role. The opportunity to build on successful programmes such as Fife ‘good conversations’ was also suggested. Finally an initiative that the community could take ownership of that relates to ‘softer’ care aspects was discussed as an area of potential. This idea of a ‘Forres Resilience Group’ could provide a pathway for retired social care assistants to continue supporting people on a more voluntary basis.

For more information:

Dr Tara French | t.french@gsa.ac.uk

Yoni Lefevre | y.lefevre@gsa.ac.uk