Identifying and supporting emerging need

Initiatives to support the most in need

At the heart of this approach is the concept of a multidisciplinary team. These teams are known locally as the Integrated Care Teams and there is one for each network. It is undesirable for a person to receive hospital admission unless necessary. Hospitals are inherently overloaded and where a stay in hospital becomes long it is likely to undermine healthy recovery.

An individual will become the subject of an Integrated Care Team when it becomes clear their needs are escalating and becoming complex to manage. This team’s purpose is to deliver care in the community, minimising the need for a hospital stay, and to plan the discharge where it becomes necessary for a patient to be admitted.

  1. The Anticipatory Care Approach

    This part of the approach is applied as a filter to highlight those most likely to require support in the future and is supported by the use of an analytical tool in General Practices to highlight those people who might be regarded as frail and/or vulnerable or having multi-morbidities who would benefit from an earlier intervention.

    The GP will assist in reviewing the outputs from the tool, applying a sense check against their consultations and knowledge of the patient. Where considered suitable, patients identified will then be discussed and reviewed by a Multi-Disciplinary Team (MDT), with the addition of a Clinical Frailty Specialist / Consultant Geriatrician.

    Recommendations and outcomes from the MDT will be communicated back to the patient’s GP; working in close partnership to ensure the best outcome for the patient.

  2. Locality Access Point (LAP)

    The LAP functions as an entry point into all community services in a locality, which will support integrated working through joint triage and assessment of needs for referrals. The LAP operates a ‘no door is the wrong door’ policy and will make it easier for referrers (currently this is for professionals only) to access services on behalf of their patients.

    The staff within the LAP are typically members of the Integrated Care Team depicted in the image above and it is the free flow of information within the team which drives the quality of outcome. They operate 8am to 8pm in line with the GP practices and will respond within 2 hours where the need of a patient is urgent.

  3. Co-located Community Teams

    The Integrated Care teams are typically co-located with the emphasis on information sharing on a daily basis so that even routine support is delivered in a joined-up way by people who have an understanding and relationship with the patient. The GP will play a significant role in providing the underlying knowledge base regarding the existence of frailty or complex needs and the clinical need for support and has direct access to the decision making in the team.

    At this stage, the team will typically comprise GP/primary care, Community Matron and District Nursing, Social Care, mental health expertise, and therapeutics where needed.

  4. Multi-Disciplinary Team (MDT) meeting

    The first purpose of the Integrated Care Team MDT meeting is to anticipate the occurrence of needs that are becoming critical and to ensure that the relevant agencies are involved and working in a joined-up way to address those needs. The MDT covers those with complex needs or who are approaching high risk of hospital admission and will seek to allocate a Lead Practitioner who will coordinate the response to the need.

    This team comprises the GP, Community Matron and District Nurse, Social Care, Therapies, Mental Health team, Social Prescribing and the voluntary sector such as our own Making Connections (run by Hart Voluntary Action).

  5. Hospital In-Reach Approach

    Once an individual is in hospital regardless of the route by which they arrived the general expectation is that they will be discharged back home as soon as appropriate. This part of the pathway must be joined up and integrated in order to avoid readmission and/or further clinical deterioration.

    To this end the discharge information and the circumstances of the discharge must be communicated to all those involved in the Multi-Disciplinary Team and the Out of Hours service in order that clinical advice is available at a level that supports the community teams working together to support patients to stay independent at home for as long as possible.

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