This page is a printable version of: http://www.onel.nhs.uk/for-health-professionals/integrated-care.htm
Date: 16 May 2012
Integrated care
Integrated care (also known as integrated case management (ICM)) is a new model of community care, based on targeted case management for people at high risk of hospital admissions. It provides coordinated care plans for people with complex needs and long term conditions. Individual care plans are prepared and delivered through the integrated working of primary, community and social care. The model aims to deliver better health outcomes, higher patient self-management of conditions, and an improved quality of life.
The projects do vary in some details between each London borough. Barking and Dagenham have been championing this new system for the past year; Redbridge and Waltham Forest plan to roll out the new model at the end of 2011. Havering is running an ICM project as part of their co-funded NHS support for social care programme with the London Borough of Havering and the North East London Community Services team now managed by NELFT. The Havering project is due to be expanded in 2011/12. We will publish details of the individual projects on the borough ICM web pages shortly.
How does integrated care/case management work?
ICM operates through regular meetings of a multi-disciplinary team across health and social care. GPs, social workers, community matrons, district nurses, practice nurses and a case liaison officer attend a fortnightly meeting at local GP practices to discuss patients with complex needs and develop strong, patient-focused care plans.
A new ‘case liaison officer’ role has been created who will coordinate meetings and paperwork for case conferences and support patients to access services.
How are people identified for integrated care/case management?
The top 1% of high risk patients who use health services are identified through NHS Health Analytics which selects those who may benefit from the integrated case management programme. This online system ‘risk stratifies’ patients from their GP health records, by looking at their condition and history of frequent hospital admissions. The case liaison officer extracts data from the health analytics system and will put forward patients for consideration to the integrated health team.
How long does integrated care/case management last for?
Integrated case management will be completed for people considered at high risk of hospital admissions. We expect that most people will be case managed for a period of eight weeks; however some people may need a shorter or longer time.
What are the benefits of integrated care/case management?
- Named social worker, community matron and district nurse for each patient
- Co-ordinated care for patients and carers
- Reduced duplication of health services
- Reduce referrals and paperwork
- Better administration and case management through the case liaison officer
- Reduced numbers of hospital stays and GP visits
- Higher quality care, improved patient outcomes and greater efficiency savings which lead to a higher quality of life for our patients across outer north east London.
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