Care Connection Team (Hillingdon Health and Care Partnership)

One of the great things about the Care Connect Team service is its multidisciplinary, whole systems integrated database which includes social care data.

Caroline Morison, Managing Director, Hillingdon Health and Care Partners

About the partnership

1. In 2017, the Hillingdon Health and Care Partnership (HHCP) established Care Connection Teams (CCTs) to deliver and coordinate care for residents with complex health needs associated with long-term conditions.
2. CCTs are a multi-disciplinary community-based teams.
3. In addition to Well-Being Assistants and Mental Health Nurses, the CCTs include Guided Care Matrons and Care Coordinators or Nurses. They work closely with GPs as well as other community services such as Social Services, District Nursing and Rapid Response.
4. Patients are identified by their GPs as needing case management as part of their care based on their physical, mental or social needs.
5. The team performs home visits to assess the patient’s overall needs as well as their specialised requirements and care needs.
6. Hillingdon patients are served by eight CCTs.

What has gone well

1. The CCTs have access to a range of services including hospital, community, social care, and voluntary sector services. This enables joined up, holistic care.
2. The CCT model of information sharing between relevant services enables people to get the right support at the right time.

Challenges experienced and overcome

1. Challenges in distributing funding between partners – the team overcame this with a collective prioritisation conversation about need and impact.

Results

1. The CCT model supports people in their own home to stay well and healthy for as long as possible and promotes self-management for independence.
2. The CCT model enables early intervention when problems first arise, reducing emergency hospital admissions.
3. Patients under the CCTs’ care can access timely and appropriate care without the need to make a GP appointment and reducing other patients’ access.
4. The CCT approach is underpinned by a focus on improving patient wellbeing and quality of life to the benefit all of the patients involved.

What made the difference

1. Regular meetings: these allow the team to monitor and review patient needs, as well as the approach to care to ensure patients are receiving the best support.
2. A shared consent form and integrated database: this enables information to be shared across partners – reducing the need for the patient to repeat their story.
3. Flexible referrals: this mean that patients can be referred for an intervention which usually lasts for five to six weeks before discharge back into their usual general practice. Patients can be re-referred if their needs change and it is appropriate.
4. Risk and gain model of funding: there is a shared pot amongst HHCP and evaluations at the end of the financial year to ensure investment is delivering impact for local people.