Integrated care

NHS Nottingham City Clinical Commissioning Group, Nottingham City Council and Nottingham CityCare Partnership are continuing to work together to integrate adult health and social care services as part of a five year programme to improve and streamline care for citizens.

The Programme includes four key project areas:

  • Co-ordinated care - a new model changing how primary care, community health services and social care services are commissioned and delivered, emphasising joined up care and proactive support
  • Independence Pathway - a new model of assessment and rehabilitation, enabling people to remain as independent as possible
  • Access and Navigation - Access to and navigation around services will be simplified and a navigator role or service will be developed
  • Assistive Technology - where the programme will support the early intervention and prevention approach which will be integrated assistive technology, harnessing products and services designed to enable independent living.

The case for integration

Integrated care aims to ‘join up’ health and social care to meet the needs of an ageing population and transform the way that care is provided for people with long-term conditions, enabling people with complex needs to live healthier, fulfilling and independent lives.

From the engagement completed with our workforce so far, and through our analysis of feedback from the engagement events and citizen feedback, there is strong evidence that the current system of support and service delivery for adults with long-term conditions or frail elderly in Nottingham City is neither as efficient nor as effective as it could be. A collaborative approach is required to ensure the best possible care and support is available to meet the needs of the citizens.

There is a strong driver for integration nationally and many other parts of the country are also working towards integrating health and social care. National evidence also shows that integration can radically improve early identification of long term conditions, self-care and proactive risk identification. It will enable us to provide the right care at the right time in the right place, a co-ordinated care approach through multi-disciplinary teams and case conferencing, an integrated assessment and care planning system and better supported hospital discharge and admission avoidance.

It’s clear also that the current health and social care systems are difficult to navigate for patients and health and social care staff, resulting in problems in accessing appropriate support. We have an increasing frail older population and a rise in people living with one or more long term conditions. These people really need us to change the way we do things – and our ways of working must put their needs at the centre of our services to help improve their lives.

Delivering integration together

The Integrated Care Programme will review service delivery models and systems, positively transforming citizen experience of how their needs are met. The development of an integrated care system for those with long-term conditions (including older people with complex needs) will be based on, and responsive to, the aspirations of the citizen and focus on:

  • Prevention
  • Early intervention
  • Maximising independence through the delivery of the right service at the right time
  • Optimising citizen choice and control

The long term vision of Nottingham City CCG and Nottingham City Council is that through an integrated strategy, within five years, citizens will see a transformed health and social care system where there is:

  • Early detection of long term conditions
  • Support to ensure that citizens are empowered to manage their own condition/s
  • A proactive approach to identify citizens at risk of needing an increased level of care to ensure appropriate support is in place before a crisis situation occurs
  • The right care delivered at the right time through Primary care, community services and social care working together in Care Delivery Groups
  • Coordinated Care through services being delivered by multi-disciplinary teams holding regular case conferences and from having collocated health and social care teams
  • Personalised care planning with access to appropriate specialist support in the community
  • Supported hospital discharge to ensure that citizens are only in hospital when they require an acute episode of care. 

The future model for Integrated Care

IC model

A new model for integrated care has been developed from direct feedback and the conversations and discussions that took place at stakeholder engagement events in January and February 2013. The model was approved by the Integrated Care Programme Board in June 2013.

The new model aims to deliver services in a way that puts the citizen at the centre, giving them more control. This means that instead of citizens trying to navigate their way round the multitude of services that currently exist, we are redesigning services to fit around their needs.

Key to the new model is the formation of care delivery groups. These are groups of key professionals working together in a specific geographical area. By aligning health and social care boundaries, colleagues we will be better able to work together around a citizen’s needs, share information and combine experience to shape continuous improvement.

By ensuring health and social care teams support eight multi-disciplinary care delivery groups and by integrating services to deliver the ‘Independence Pathways’, we can be more joined up and responsive to the needs of citizens. This will avoid duplication of time and paperwork and result in more holistic care.

The model will be implemented in three phases with phase one starting in early 2014. Phases two and three will be developed over the coming months using feedback, knowledge and experience of the workforce to input into plans through on-going staff engagement. More details of the work to be undertaken in phases two and three will be communicated through this website, future staff briefings and issues of the Connecting Care Newsletter.