The challenge

With integrated care systems now a reality, there is a renewed ambition to improve care through more joined up multi-disciplinary local teams.

Communication across different health, social care and third sector organisations is vital but organisations using different IT systems find it difficult to share information and work together.

Also, third sector organisations do not always have the digital capabilities to communicate efficiently with their health and social care partners; they are reliant on phone, email and spreadsheets to share information.

This lack of ability for partners to easily and securely co-ordinate care and subsequent actions can lead to slow decisions, wasted resources and an increased risk of delayed care.

To respond to the COVID-19 crisis in March 2020, the CWH needed a way for local teams from different organisations in BaNES to work together, share resources and co-ordinate care.

Even now, with the cost of living crisis and supporting people with ever complex needs, this challenge for the hub remains.

RIVIAM's solution

Since March 2020 to date, teams from over 20 different partner organisations are using RIVIAM to work together and share information providing support for local people.

The hub continues to respond to pressure on the health and care system, most recently creating a support team at the Royal United Hospital Bath to help people once they are fit to leave hospital.

There are many ways people can request help from the hub.

People can call where a short online referral form is completed in RIVIAM. Professionals can complete an online referral form available via the CWH website and ward staff at the Royal United Hospitals Bath can complete an on ward Checklist for in patients.

Referrals are all auto routed to RIVIAM.

Each partner organisation is set up with a pathway to receive referrals and it’s simple to see demand and manage the progress of requests across different services.

Red, Amber and Green statuses are set for each pathway to highlight the length of time a case has been in the system.

Security measures mean only users authorised to access certain pathways can do so, meaning data is managed securely and responsibly whilst enabling multi-agency working.

Authorised users can see the full history and a single view of all activities about a person and their care with a full audit of who has done what and when. New outcome tracking enables outcomes to be tracked and reported.

RIVIAM will soon be enabling authorised partners to have a link via RIVIAM to the local Integrated Care Record enabling a more holistic view of a person's needs.

Benefits for organisations

• Multi-agency working - team members from BaNES Council, HCRG Care Group and third sector services such as Age UK BaNES, Bath Mind and Curo can work together across the same patient record, where they have the access rights to do so. Organisational boundaries are removed and Multi-Disciplinary Team meetings are easier.
• Managing demand - removes the need to track cases in spreadsheets and on whiteboards.
• A different culture - working together on RIVIAM supports a different culture with shared responsibilities, resources and working practices.
• Single view - team members can see the latest position for the person and look up information when they are on the go in the community.
• Responsive and reactive - organisations can mobilise quickly to respond to ever changing services pressures and demands

Outcomes for people

• There is no 'wrong door' to access services.
• Services are ‘wrapped around’ individuals. No person is ever left without support or an agreed plan of step down support.
• Gaps in care can be identified more easily and support put in place.
• People receiving support don’t have to waste time repeating conversations as services have access to the person’s record, if they have the rights to do so.
• Using RIVIAM, council officers and healthcare professionals can create new referrals for Ukrainian refugees and their sponsors within minutes. Teams can record actions on RIVIAM as they carry out post-arrival health and wellbeing checks and they can easily raise referrals for other third sector support services.

Explore the benefits for you

If you would like to explore how health and social care organisations can work together on RIVIAM in your area, contact us for a demo.