Integrated Neighbourhood Care Teams

Developing Integrated Neighbourhood Working

“To empower people and communities to take an active role in their health and wellbeing with greater choice and control over their care.  It supports the improvement, integration and personalisation of services”.

The Lincolnshire Health and Care community aspires to a population based model of health and care where wellbeing is maximised through communities, voluntary and statutory services working together. Integrated Neighbourhood Care Teams are now being established with evidence of improved outcomes for a small number of patients. Our Phase 2 work has commenced, with all partners to enable teams to further integrate and increase numbers seen. The concept of delivering integrated community care has been a strategic driver for the Lincolnshire Health and Care community for some considerable time and some work has taken place to see this happen. The Proactive Care Programme has developed a number of work streams designed to deliver preventative and pro-active services aimed at reducing the demand on acute care and long term care for Adult Social Care and to support people to remain well and independent for longer. As part of this the Pro-active care work stream developed the following design principles for the proactive care model:

  • Co-ordinated and delivered in a multi-disciplinary team focussed around primary care.
  • Multi skilled team members who are empowered to act and be accountable
  • Locality / neighbourhood / geographical delivery
  • Enabled by technology
  • Interfaces with specialist and acute services

Using these principles work commenced with our health, social care and 3rd sector colleagues to design and implement the Integrated Neighbourhood Care Team model. The teams are also following a developing set of operational principles to guide their work, these include:

  • Prevention – first and foremost
  • Think Home First
  • Discharge to Assess
  • Comprehensive Geriatric Assessment
  • Taking responsibility and being accountable

The design of the teams is based on both national and international evidence of where this approach has already been adopted and has shown some evidence of impact. It is expected that Integrated Neighbourhood Care Teams will work together to deliver a range of functions on a basis of need to its local population. Whilst initially the focus for the Integrated Care Teams will be the support and management of older people, over the next 5 years this model will incorporate children and younger people as a ‘whole population’ model. The Care Teams will comprise of a range of multi-professional staff with the core team including:

  • Primary Health Care – GPs and their team
  • Community nursing
  • Therapy and re-ablement
  • Community Mental Health Teams
  • Adult Social Care – names social workers
  • Clinical and non-clinical care co-ordinators

This core team will then be able to rapidly access a range of services and support, for example:

  • Third Sector Services – Wellbeing Service
  • Lifestyle services
  • Carer support
  • Specialist services eg. Specialist nurses, community geriatrician, mental health
  • Special end of life carer
  • Transitional care support (step up / step down) – See intermediate care section
  • Housing services

The emphasis of the work for the Integrated Neighbourhood Care Teams has been to develop systems and processes to work together to identify increasing vulnerable and high risk patients, particularly patients at increasing risk of a hospital admission and from this deliver a more pro-active response in line with individual patient and carer needs. These teams form part of a wider set of system developments which are inextricably linked, eg Transitional Care, Clinical Assessment Service, Contact Centre and Rapid Response, acute hospital Integrated Discharge Hubs, all of which are essential to deliver an effective, safe, integrated pathway of care for older people.

This is an exciting time for the people of Lincolnshire as we collectively embark on this whole system change programme. Including what we have achieved so far and where we are going by building on existing successes as a multi-agency team – this is Integration in Action!

What is an Integrated Neighbourhood Care Team?

Neighbourhood Care Teams currently bring together health and care professionals in a local area who can work together to support people most at risk of health and social care problems.

Neighbourhood Care Teams will keep people independent for as long as possible and help to avoid unnecessary hospital admissions. Essential services in the team include:

  • General Practice (GPs)
  • Nursing Services
  • Therapy services
  • Mental Health service
  • Social Care Services
  • Reablement Services

These professionals are linked into the local community and can ensure that residents get a genuinely joined up approach from wider support services. By bringing together health, social care and community in a person-centred approach we can empower individuals to live more independently and provide support to manage their care more effectively.

NT Model

Why are Integrated Neighbourhood Care Teams needed?

The number of people living with one or more long term health conditions are rising, leading to more complex needs. This coupled with an increasingly ageing population increases the risks to individuals’ wellbeing. It is shown from success stories in other parts of the country that identifying most at risk individuals and treating them with a co-ordinated, integrated and proactive approach leads to an improvement in health and wellbeing.

How will Integrated Neighbourhood Care Teams work?

Patients can be referred to a Neighbourhood Care Team through a variety of routes where their case will be managed by a Care Liaison Officer. If clinical knowledge is needed, a Care Co-ordinator may be assigned to the individual. Neighbourhood Teams will deliver more coordinated care in the community enabling people to manage their own conditions and reducing the need for hospital admissions.

How do I access my Neighbourhood Care Team?

Currently the Neighbourhood Team Care Liaison Officer acts as a coordination point to help the individual access services and support. Now the teams are up and running and the next step is to look at how they can be developed to meet the needs of the wider population.