North Norfolk Integrated Care Programme
● What is ‘Integrated Care’?
Integrated care is designed to ensure that you receive the right health and social care where and when you need it. It aims to provide you with care that is co-ordinated and linked to local services in your community.
If you are someone with a range of illnesses or complex needs, you may see many different professionals who help to manage your care and ensure that you are getting the best support and treatments available.
An integrated care approach brings together all professionals to work together as a community care team.
● What does a multi-disciplinary team do?
A multi-disciplinary team is usually led by your GP and based at your local GP surgery. Depending on your individual needs, the team may consist of a range of health and social care professionals, such as a community matron, a link nurse, a social worker, a therapist, mental health and learning difficulty specialists and an integrated care co-ordinator. One of the team members will be your named lead worker.
The team gets together to discuss your treatment now and in the future, and decides if:
- any of your care can be streamlined and be made more effective
- you might benefit from a referral to other services
- you might benefit from further tests
- there is anything else you could receive to help improve your
- independence and wellbeing
● What are the aims of an integrated care meeting?
The aims of an integrated care meeting are to improve the co-ordination of your care, and to improve communication between professionals so that you receive the most appropriate care for your needs.
● Who decides if I could benefit from an integrated care meeting?
A GP, health or social care professional involved in your care will decide if an integrated care approach could benefit you and will discuss this with you.
You will be asked to give your permission to have your medical record shared with the professionals involved in your care. Your information will then only be shared with those authorised professionals.
● What does this mean for me?
Your GP or lead worker will contact you so that you are involved in any recommendations or discussions from the integrated care meeting. You will remain at the heart of all decisions involving your care and may at any time opt out of receiving integrated care support.
You will continue to be reviewed by the multi-disciplinary team until your needs have been met. Should your needs change you can benefit from integrated care support at any time in the future.
Keeping Providers and Organisations informed
Integrated Care Coordinators
The Integrated Care Coordinators play a vital role - acting a a link between the patient and organisations best placed to provide their care. There are 8 ICCs who work across all our GP practices and co-ordinate how a patient's needs might be best met. Watch the short film below to find out more about what they do.
A day in the life of Stephen Little - Integrated Care Co-ordinator
ICC’s work across health, social care and the voluntary sectors, making sure the right services are both in place and providing joined-up care and support, while helping people make those informed choices which will keep them independent and safe in their own home. It’s a fascinating role and we’re learning all the time!
9am - I arrive to work half a day at the GP surgery. In this particular practice, I work in the GP Secretary’s office, just across the corridor from the tea break room, which gives great opportunity to mix with staff and GPs. It’s those informal discussions which can often prove the most valuable.
Mid morning - I’m contacted by a lady who I had previously sent information to help her get an alarm.. She’s concerned she may not get physio treatment soon enough. I messaged the GP to ask about her having physio at the surgery, and (at her request) looked at private options for her. She was also interested in the meals service, so I contact two providers on her behalf who agreed to send brochures and do a follow-up call.
For the rest of the morning I work on several different referrals at once, which come to us typically from community health staff, social workers and monthly multi-disciplinary meetings with the GPs at the surgeries. This requires a good degree of self-organisation, as well as having to update information in a variety of formats to keep all services informed and to track the overall progress of patients.
1pm - I relocate (cycling in this case!) to our own office. I go back to the previously mentioned lady’s additional concerns about her future care options. I discuss with a social care assessment with the OT, and it’s agreed to contact the family first to establish their level of input. Another conversation…another minor decision, but all part of an integrated approach to ensure that the community can work with all service sectors in a way which is informed, mutually supportive and always open to improvement.