From Mike Bomford, Exeter 382173, April 01, 2008

Integrated health and social care teams are helping people with complex care needs to continue living in their own homes.

Devon County Council, Devon Primary Care Trust, and care providers in the voluntary sector are working together in teams in the Exeter area, as a pilot before integrated teams are introduced across the county.

Exeter has two Complex Care Teams comprising Community Nurses and Matrons, Occupational Therapists, Social Workers, Community Care Workers, Domiciliary Pharmacists, Assistant Practitioners, Rapid Response Staff, Physiotherapists, Community Psychiatric Nurses, and representatives from the local Voluntary Sector.

The teams' purpose is to identify at an early stage people who, through ill health, are at risk of losing their independence, and to intervene with vital support to help them continue living at home. The aim is to reduce or hopefully avoid the need for hospitalisation or for long term residential and nursing care.

People with complex care needs and conditions that previously may have prevented them from continuing to live at home are now receiving a programme of integrated support to help them remain as independent as possible.

Because the multi-disciplinary teams are integrated, information about people's conditions and care requirements are shared among the relevant professionals, avoiding duplication and making the services run far more efficiently.

Mrs Jones (not her real name), aged 72, from near Exeter, is very pleased with the support she is receiving from her local Complex Care Team.

Mrs Jones lives alone and has a history of hospital admissions due to having Chronic Obstructive Pulmonary Disease (COPD) - a term used for people with chronic bronchitis, chronic asthma or chronic emphysema, or a combination of the three.

COPD affects about a million people in the UK. The symptoms include coughing and breathlessness and a flare-up of COPD is one of the commonest reasons for admission into hospital.

Mrs Jones' condition had reached a stage where even minor exertion left her breathless. She could do very little for herself, and therefore was feeling isolated and fearful for her future.

She was referred to the Complex Care Team by her GP, and was assessed by Rachel, her Community Matron.

A care plan was drawn up which includes visits by domiciliary carers for a few hours' personal care each week.

A Community Pharmacist visits to help her with, and to monitor, her medication.

Occupational Therapists visited her at home to decide what practical assistance she may need to live at home, and arranged for installation of a stair lift.

Her GP also visits her whenever necessary.

Complex Care Teams meet each week to discuss clients' progress, so information is shared between the relevant professionals. Hospital discharge facilitators and senior nurses are also part of these teams, and there is a single point of contact for GPs and other professional staff.

By talking to her Community Matron, Mrs Jones has learned much more about her condition and about what she can do to limit preventable admissions to hospital.

Although Mrs Jones relies on oxygen therapy to help her breath, she is a lot happier now with her circumstances than she was. The stair lift means that she is able to go upstairs to bed safely. Her medication is working, and she understands her condition and has learned to recognise oncoming attacks of breathlessness.

One of the most rewarding aspects of her improved condition is the fact that she is involved, once again, in her grandson's care, before and after school.

Her trust in Rachel, her Community Matron, has also given Mrs Jones the confidence to accept her condition and to maximise her quality of life.

"I am comforted by knowing that I am within a system that is working well," she said. "The team is very joined up, much more so now than in the past, and I am confident that it works well.

"I used to think 'if only people would trust each other to share information', then services would be better. And now the information is being shared.

"I have come to understand that I am no longer in complete control of my life, but with the support from the team, I am able to cope with that realisation with confidence.

"I especially enjoy the visits from my grandchildren, who are very helpful to me.

"With my condition, I would find it very hard to manage without the support I am receiving.

"I'm very fortunate," she said.

Complex Care Teams are part of the way that old boundaries between health and social care are gradually blurring.

As part of Devon's overall strategy to integrate health and social care fully by the middle of 2009, Complex Care Teams for adults will become established across Devon within 'cluster' areas that are aligned around existing GP practices.

Councillor John Rawlinson, Devon County Council's Executive Member for Adult and Community Services, said.

"Mrs Jones story is a good example of how integrated working is helping people much more effectively than had those services been delivered separately without the same coordination.

"Setting up a multi disciplinary team allows us to focus care on the person, so that we can ensure that we provide the right intervention in the right place, at the right time, by the right person.

"We're able to work in partnership with people to help them manage their condition, avoid unplanned hospital admissions and remain at home for longer.

"Our records indicate that we have reduced the number of emergency admissions to hospital compared to figures of over a year ago. And in so doing, we are giving people more choice about their care and the opportunity to continue living at home for longer."