New care models and social care

On world social work day, Samantha Jones, Director – new care models programme explains how social workers are playing a vital role in changing the way we deliver care.      

Recent developments have seen social workers play a key role in integrated care teams, which support older people and those living with long-term conditions to manage their own health independently at home. While the care teams promote and support independence, they also reduce the need for residential care packages and the cost of long-term community support. They can also be a vital way of flagging up health concerns quickly by being able to directly contact the relevant health professional.

The integrated care teams are a combination of nursing and adult social care teams, and they work with local GPs and specialist nursing and therapy teams to identify those in greatest need of support. Individual care plans are created and delivered by a multidisciplinary team, with each patient assigned a care coordinator: this could be a social worker, district nurse or therapist.

Such care plans may see the provision of additional support services, or help with home improvements. Here the role of the social worker is key. They help ensure equipment is provided, such as telecare devices like falls sensors, and they will modify individual care packages, such as arranging packages of care where there is none already, repeat an assessment to see if a patient needs further support, or arrange short-term crisis support and rehabilitation.

There are some great examples of how this is working across the country. For example at  Mid Nottinghamshire Better Together vanguard 83% of referrals to the integrated care team between July and September 2015 were people aged 70 or over, and “physical support” was the primary reason for 56% of overall referrals.

Chris was left paralysed 28 years ago after surgery to correct a spinal disorder. He runs an accountancy firm from home and while he uses a wheelchair, he can only be in it for around four hours a day, spending the rest of his time in bed.

He is visited by carers four times a day and the Mansfield and Ashfield integrated care team also provides daily care, helping him to manage his diabetes and providing nursing care.

Chris also suffers from pressure ulcers, but had previously been refused a hospital bed at home. However, the social worker in the integrated care team ensured an application was made and Chris received the new bed.

He said: “It has proved invaluable to my care. It makes getting in and out of bed much easier, and I’m less likely to catch myself; a small graze can develop into an ulcer. The team also organised specialists to come out and assess me and make sure I had the right equipment. It was good teamwork.”

An earlier response to a sudden change in a patient’s condition is another benefit of the social care team’s role in integrated care. At the Harrogate and Rural District vanguard, closer working between health and social care professionals, and better sharing of patient information, potentially meant all the difference to a person with complex mental health issues.

A social worker was visiting the person when a rapid change in behaviour caused major concern: the social care manager was able to arrange for a mental health assessor to go out the same day to confirm that it was safe for the social care worker to continue to support the person.

An escalated situation was avoided thanks to different team members being able to call on each other for expertise and support.

On world social work day, it’s great to celebrate this teamwork and recognise the important role of social workers in transforming care for patients and communities.

Samantha Jones

Samantha Jones is NHS England’s Director for New Models of Care.

Samantha Jones was appointed as NHS England’s New Care Models Programme Director in January 2015 leading the implementation of new models of care as outlined in the NHS Five Year Forward View.

She started her NHS career as a paediatric and general nurse and was a national management trainee. Having worked in a variety of operational management roles, and in the national clinical governance support team, she became the Chief Executive of Epsom and St Helier Hospitals NHS Trust.

Following this, Samantha worked in the independent sector before she was appointed Chief Executive of West Hertfordshire Hospitals NHS Trust in February 2013.

In 2014 she was awarded Health Service Journal Chief Executive of the Year and the trust’s “Onion” was highly commended in the patient safety award.