Health and Social Care Joint Working

Governing Principles of Joint Working

Developing a supporting infrastructure

There are four key essentials that must be present in order to develop an infrastructure that supports joint working:

• Robust communication structure
• Simplified service access
• Easier referral and information sharing across organisational boundaries
• Jointly agreed processes that follow national governance and legislation

Reporting/communicating structure

Tameside Older People's Steering Group
		SAP Steering Group
Joint I.T. Sub Group		Joint Information Sharing Sub Group		Joint Protocols Sub Group

Single Access Points

Currently there are three service areas that are accessible through a single point of access, i.e. single telephone number.

Mental Health referral process

	RIAS - single point of entry for: Dementia CMHT - Older People Hyde Day Hospital HIT (Home Intervention Team) Psychologists Specialist OT
	Weekly multidisciplinary allocation meetings
	Possible outcomes of these meetings:
No diagnosis or query		Joint work with Social Care and Health (formerly known as Social Services)
Hyde Day Hospital (screening day clinic)
Outpatient appointment Social Care and Health Services Internal Teams Discharge

Intermediate Care referral process

Home: GP Social Worker Nurse	Hospital: Transfer Service
Intermediate Care - Single point of contact
Criteria must be met: 18yrs+ Tameside or Glossop resident Medically stable Rehab potential Mental Health not the primary problem
Range of interventions: Shire Hill Hospital Extra Care Flats Resettlement Team Community Rehab Team

Social Care and Health referral process

Adult Assessment and Customer Care Team (AACCT)

		Contact via: Telephone/fax/email/post/mini-com/front desk
Joint work with Mental Health, Intermediate Care, specialist services, Learning Disability Service, Housing		Customer Care completes contact assessment and applies eligibility criteria		Work passed to lack office teams for long-term care coordination, specialist assessments and care provision that takes over 2 weeks
Social Workers - same day response and protection of vulnerable adults (PVA)		Work allocated and completed in AACCT		Category 3 - advice and information/re-direction/provision of simple service
Category 2 - assessors complete overview assessment, provide services and care manage within 2 weeks		Specialist assessment/provision		Further home visits if more information required to come to an outcome

Access point for all District Nurse bases and at the Transfer Service (TGH)

Referral Source GP Hospital Primary Health Care Team Carer Self
Referral must require a specific nursing intervention
No		Referral accepted		Yes
No nursing need identified			urgent requiring visit within 4 hours non-urgent, contact made within 24 hours
Refer back to source	Refer to other services in necessary		Home visit required	If patient mobile appointment made to attend clinic
Negotiate plan of care/consent to treatment Care given/treatment delivered either at home or clinic based Ongoing assessment and evaluation Care/treatment complete Discharge			Assessment

SAP IT Interim Solution System

This is a web based system hosted by Social Care and Health, (formerly known as Tameside Social Services), providing social care information to health staff in order for them to be able to make informed decisions regarding need for referral / assessment.

The database allows for the electronic exchange of relevant information, notifies appropriate individuals of their need for action and reduces the amount of duplicated information within separate agencies. The system also includes a resource database; a SAP community notice board and 'non SAP' email messaging facilities.

SAP Information Sharing Agreement (ISA)

This is an agreement between the SAP Community, which contains details of information sharing which is specific to the integrated assessment process. The SAP community is defined as a set of organisations, which use a common SAP methodology and have common procedures.

It provides a framework for the secure and confidential sharing of SAP information between organisations in a SAP Community to ensure:

• Service users receive the health and social care they need.
• Organisations can provide seamless and coordinated care.
• Organisations work effectively and efficiently together to tailor services to the particular needs of each individual.

It does not cover the general principles of sharing information between organisations, as this is covered by a separate Information Sharing agreement.