Delivering joined up care


Seventeen Integrated Care Partnerships (ICPs) are working in local areas to transform care for frail older people and those with long-term conditions. Each ICP is a network of GPs, pharmacists, health and social care staff, voluntary and community groups, local councils, service users and carers, all working together to deliver joined up care.

Health Minister, Michelle O’Neill recently attended the ICP Regional Workshop, addressing delegates and speaking with ICP members. The Minister said: “I strongly believe that Integrated Care Partnerships provide an excellent vehicle through which we can maximise our own existing integrated care system and combat some of the difficulties which we have encountered to date in reaping the full benefits of our system. I wish to continue with the process of restructuring our health service and move to a service that is focused on co-operation, integration of services and patient centred care.”

To find out more, we asked some of those leading the delivery of ICP initiatives to outline some key service changes.

Dr Alan Stout

Chair and GP lead of the East Belfast Integrated Care Partnership:

Acute Care at Home is one of the key projects established by the Belfast ICPs. Supported by £1.74 million funding from the Belfast Local Commissioning Group, the service provides people over 75 with expert medical and social care in their own home, avoiding the need for hospital admission. Patients referred to the service have, within their own home environment, the same access to diagnostics as hospital inpatients and receive consultant-led assessment and treatment.

The service is an excellent example of a truly joined up and innovative way of working that is providing a better experience for patients, their families and carers; and is helping to reduce pressure on hospital services. Outcomes to date have been highly encouraging; in particular the feedback from those receiving the service and their families has been extremely positive. Throughout 2015/16, the service supported 274 older people to remain in their homes and avoid 3,014 days that would otherwise have been spent in hospital.

Dr Chris Leggett

Chair and GP lead of the Down ICP:

ICPs in the South Eastern area established a new coordinated falls service. Paramedics attending a call out to an elderly patient who has fallen in their home, but does not need to go to hospital, can now make a direct referral to a falls assessor. The assessor will then visit the patient at home within 24 hours to provide support and advice; identify and address any risks which could lead to further falls; and to coordinate any necessary referrals to a range of other medical services (as appropriate) and community, voluntary and social services available in the local area. Strength and balance exercise programmes are also being promoted and delivered to help people to maintain independence, mobility and coordination as they grow older.

This is an excellent example of the type of enhanced medical and rapid social care response that enables people to stay in their own home and avoid unnecessary hospital admission. As well as reducing the risk of falls and fractures, the service also addresses loneliness and isolation, building confidence amongst patients and improving social interaction.

Dr David Rodgers

Chair and GP lead of the Armagh/ Dungannon ICP:

Southern ICPs led on the development of a pilot Rapid Access Respiratory Clinic at Craigavon Area Hospital to help prevent hospital admissions for those suffering from long term respiratory conditions. Working together the members of the Southern ICPs designed this innovative service, secured funding from the Southern Local Commissioning Group and established a real alternative to hospital admission for patients whose respiratory conditions have worsened.

During an initial pilot (September 2015 – January 2016); referrals were made by the patient’s GP or the Community Respiratory Team in the morning for appointments on the same afternoon. By receiving specialist intervention and treatment at an early stage and preventing future deterioration of their condition, 73 per cent of patients avoided going to the Emergency Department and 50 per cent of those treated did not require hospital admission. Discussions are ongoing to hopefully see the service re-established as a permanent clinic later in 2016.

Dr Ian Kernohan

Chair and GP lead of the East Antrim ICP:

Working together, the ICPs in the Northern area designed a Nursing Home In-Reach training programme to upskill and support nursing home staff to care for acutely unwell residents. This involved training in long term conditions management and recognising changes in the patient’s condition; and enhancing clinical skills.

The initiative was piloted in Antrim/Ballymena area and reduced the number of nursing home residents attending the Emergency Department by a third in 2015/16, thereby helping to avoid 1,519 days that would otherwise have been spent in hospital. Feedback from our ‘champions’ who have taken part in the training has been highly positive in terms of building confidence and enhancing patient care.

Tony Doherty

Chair and community sector representative of the Derry-Londonderry, Limavady and Strabane ICP:

ICPs in the Western area developed a unique Social Prescribing programme to help those over 65 to address social, emotional or practical needs by linking them to sources of support and activities within their local community. Older people who may not require a medical prescription can self-refer or be referred to the programme by their GP or another health professional to receive onward support from a dedicated Social Prescribing Coordinator and access the most appropriate local community and voluntary services. The Coordinator will then remain in contact to review progress.

Following an initial successful pilot, the service has extended to six GP practices across the Western area covering a population of over 63,000 people – delivered by Bogside Brandywell Health Forum partnership with Derg Valley Healthy Living Centre. This highlights that, through working with community and voluntary partners, there is a real opportunity to make a difference to enhancing the health and wellbeing of older people to help them live as full a life as possible.





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