Integrated Care Teams

What are Integrated Care Teams (ICTs)?

Integrated Care Teams (ICTs) are multi-disciplinary teams designed to focus on maintaining the health and wellbeing of people in their community. They include staff from social, community, mental health, primary care and some outreach services provided by secondary care.

ICTs focus on the following values:

  • Enabling people to lead independent healthy lives at home.
  • Providing good quality care that is joined up including timely access to appropriate services as well as assisting people to make important life style choices.
  • Providing medicine optimisation and education around prevention and condition management.
  • Maintaining primary care as the principle gatekeeper and point of entry to secondary care.
  • Encouraging and wherever appropriate assisting and promoting people to self-manage their own care.

ICTs put the person at the centre of the new model of care.

Dr Amanda Britton, North Hants GP Alliance:
“This is the first time as a GP I can see integrated care really starting to happen in North Hampshire, giving our local population access to a range of specialised health and social care through one single community based team.”

How do ICTs work for local people?

ICTs bring specific benefits to the way people are cared for and involved in their own health and wellbeing, including:

  • Integrating care for people in the community by bringing together physical, mental health and therapy staff under a single team structure and providing direct support to care from clinicians working in primary and secondary care.
  • Supporting the early identification of people who require intermediate care.
  • Establishing a known caseload that can be monitored and managed more effectively.
  • Wrapping clinical care around the person in order to provide timely inputs to their care.
  • Enabling proactive case management of people with long term conditions alongside newly diagnosed patients.
  • Reducing the number of avoidable admissions by providing a rapid response team to support clinically unstable patients and partly to support timely discharge from hospital.

People undertake a single assessment with a Trusted Assessor, telling their story once which improve their experience and make it more straight forward to receive the care they need including the following benefits:

  • Fewer appointments with less travelling.
  • Reduced risk of admission to hospital or residential care.
  • Wrap-around care provided within or close to people’s homes.
  • Improved experience of health and social care service provision.
  • Improved independence and control over when and how services are provided.
  • Improved coordination of services especially for people with multiple health and personal care needs.

Who is in the ICTs?

  • GPs and Practice Nurses
  • Community and Mental Health Nurses
  • Physiotherapists and Occupational therapists
  • Social workers including reablement specialists
  • Condition specific support staff e.g. Heart Failure, COPD, Diabetes, Parkinson’s, Palliative care, MS, etc.
  • Geriatricians (from secondary care)
  • Pharmacists
  • Psychiatrists.

Who do ICTs support?

  • People with multiple health and social care needs.
  • People with complex health needs including high number of GP attendance and/or hospital attendances, requiring additional assessments, at risk of admission to secondary care, poly-pharmacy, falls risk, those showing signs of personal and/or carer neglect or and/or requiring safeguarding.
  • Older people - particularly those individuals with long term conditions, complex care needs and/or who are approaching the end of their life.
  • ‘High intensity service users’ - identifying people who would benefit from early intervention around condition management to avoid them becoming a high user of services.
Each team develops individual care plans for patients.

How do ICTs work?

There are four ICTs working in North Hampshire each aligned to a group of GP practices.

Each team does the following:

  • Operates seven days a week providing an 8am-8pm service supported by main Out of Hours service providers such as South Central Ambulance Service [SCAS] and North Hampshire Urgent Care [NHUC].
  • Processes referrals from health and social care professionals via a single point of access.
  • Ensures a trusted assessment is undertaken with a patient, telling their story once - that includes their family/friend or carer, as appropriate.
  • Works with professionals to develop their patient’s individual care plans.
  • Ensures assessments for personal care support are based on need - including reviewing packages of care for people whose health and wellbeing status is deteriorating – as well as supporting Continuing Health Care assessment in the community when triggered.
There is also a fifth team, Joint Emergency Team (JET) which:
  • Provides rapid response support to prevent a hospital admission or to support early discharge from hospital.
  • Enables a range of health and personal care interventions to be put in place quickly and may include specialist inputs from the Acute Hospital via a geriatrician and/or the patient’s own GP.
  • Is available seven days a week providing an 8am-11pm service across all four ICT areas.
  • Manages referrals via a single point of access.

Nicky Seargent, Southern Health NHS Foundation Trust:
“We have been working towards integrated care for some time and this is a major step forward in genuinely joined up care. This has been made possible due to the dedication and commitment of the staff involved and for that we thank you.”

How so ICTs work day-to-day?

Link professional
Individual team members based in the community are being asked to provide liaison support to individual GP Practices as a link professional.

Single Point of Access [SPA]
ICTs operate using a single point of access to channel referrals from local GPs as well as from the local acute hospital.

Meetings
Regular ICT meetings are held to channel multidisciplinary liaison and co-ordination via a number of regular case management/care planning meetings.

Technology and Buildings
Teleconferencing software is being piloted by some providers to support ICT meetings. It is hoped that the cascade of this technology to operational teams will improve efficiency by reducing travel times between ICT localities and the new ICT hubs.

Where do ICTs work in North Hampshire?

There are four ICT teams in North Hampshire, each team aligned with GP Practices.

There is also a fifth JET team to provide rapid response support across the four ICT areas:

Rural West
Oakley & Overton Surgery
Kingsclere Health Centre
Clift Surgery
Tadley Medical Partnership

Basingstoke East
The Bermuda & Marlowe Practice
Chineham Medical Practice
Crown Heights Medical Centre
Rooksdown Practice

Basingstoke West
The Gillies & Overbridge Medical Partnership
Camrose Medical Partnership
The Hackwood Partnership
Bramblys Grange Medical Practice
Beggarwood Surgery

Rural East
Odiham Health Centre
Hook & Hartley Wintney Medical Partnership
The Wilson Practice
Boundaries Surgery
Chawton Park Surgery
Bentley Village Surgery.

ICTs are set in the national context of creating a seamless health and social care service:

“We need a health and social care system that is truly seamless so that people receive the right care and support at the right time, in the right place.”

“At the same time, services are under intense and growing pressure and to succeed, we need radical transformation. We need to embrace and develop innovative solutions and truly integrated multi-agency working so that local health and socialca re systems work as a whole to respond to and meet the needs of people who use health and care services.” NHS England

Integrated Care Teams are a partnership between:

Southern Health NHS Foundation Trust
Hampshire County Council
North Hampshire GP Alliance
North Hampshire Clinical Commissioning Group
South Central Ambulance Service
North Hampshire Urgent Care.

Jointly commissioned by North Hampshire Clinical Commissioning Group and Hampshire County Council - Adult Services.