Delivering integrated community care

Delivering integrated community care

Why is this important?

NHS Lincolnshire delivers a vast range of services in the community, some unseen by the general population because they happen in a person’s home or somewhere other than a GP surgery or usual building. While the providers involved do an excellent job, people tell us they often have to see lots of different people and the care they receive can be disjointed leading to duplication and even worse, gaps.

People have to tell their story multiple times and because of internal policies staff are unable to provide the right care at the right time, even when they have the skills and ability to do so.

Furthermore, people and their families don’t know what to do when their symptoms worsen, or they can no longer complete everyday activities. This lack of understanding and fear of ‘wasting people’s time’ often means that they only seek support when they have reached crisis point.

To complement the services provided by the community teams, people often have regular, scheduled appointments with a disease-specific specialist. However, these appointments don’t always coincide with a change in symptoms, so people have to wait or go via their GP for help and risk becoming more unwell as a result.

A more person-centred approach would avoid delays in treatment and reduce the number of frail people or those with long-term conditions being admitted to hospital. Evidence shows that after a stay in hospital many people are unable to return home as they lose the ability to do daily tasks such as washing, and dressing.

We also know that the number of people living longer is set to increase which means the demand for urgent care will increase. If we don’t update our current model of health and care, the pressure on our workforce and finances will be too great and we won’t be able to cope.

What we’ll do to provide integrated community care:

  • 1. Increase the primary care services in the community

    Together we will:

    • Work with those who provide care in the community, such as GPs, pharmacists, community teams and voluntary groups, to understand local health needs and identify people at risk, for example, those living with mental health conditions, frailty or undiagnosed conditions such as heart failure.

    • Provide personalised care and support plans for people at risk, centred on what matters to them and involving relatives, carers and care workers etc. These will include a review of their medical history, diagnoses and medications as well as advice on health, wellbeing and prevention and who to call in an emergency.

    • Consider individual needs and provide holistic support to help people access the right services at the right time for them.

    • Connect people to activities, groups and services in their local community that provide practical, social and emotional support.

    • Regularly review care plans and identify triggers that would prompt additional reassessments.


  • 2. Simplify access to additional support

    Together we will:

    • Support clinicians and professionals caring for people (for example those who are frail or have a long-term condition) to come together to develop the best plans for peoples’ care, whether this is at home or in hospital.

    • Establish support teams who will work quickly and effectively to assess people and bring together the services and support needed to ensure a smooth transition into further care, regardless of where the person enters the health care system.

    • Provide access to additional support seven days a week which will include expert advice from senior specialist clinicians.

    • Encourage clinicians to work closely with the East Midlands Ambulance Service (EMAS) to support non-emergency calls, with the aim of preventing them from escalating.


  • 3. Integrate services around the person

    Together we will:

    Establish a ‘team around the person’ approach to integrated community care services. This will include:

    • Supporting independence at all stages of life with a focus on prevention as well as cure.

    • Working with people, communities and the voluntary and community groups which play a vital role in promoting health and wellbeing locally as equal partners – enabling people to access the right care at the right time, and reducing the need for people to travel further afield.

    • Coordinating care and improving joint working so people don’t need to keep repeating their story.

    • Putting people’s wishes at the centre of care plans and providing access to disease-specific specialists as and when needed.

    • Giving all professionals who provide care access to shared digital health records.


  • 4. Integrate our workforce to create outstanding, responsive care

    Together we will:

    • Improve working relationships between health, social care and the third sector to focus on patient rather than organisational needs.

    • Develop new roles to better support local communities’ healthcare needs and create jobs for local people.

    • Help staff to understand the importance of working with people on issues that matter to them, and give them the ability to do so.

    • Establish integrated community care teams and improve access to, and awareness of, services available closer to home.


How will this benefit people and communities in Lincolnshire?

People will benefit from the skills and expertise of a range of professionals from the NHS, social care, primary care, voluntary and community sectors. They will work together as one team to support people in their homes and communities, reducing the need to travel long distances. People will only have to tell their story once and feel listened to and there will be no duplication of similar services or gaps in care. Specialist teams will work alongside GPs and community-based teams to create shared-care agreements which will give people access to the care they need when they need it. People will also have a personalised care plan, focused on prevention as well as cure, which all professionals will follow. People will be supported to age well, and risk factors such as increased frailty will be better managed and supported.

How will this benefit clinicians and professionals working in the NHS in Lincolnshire?

More people with frailty and long-term conditions will be safely cared for in their homes and have personalised care plans that can be shared and accessed by all clinicians. Working collaboratively as one team, regardless of organisational boundaries, will reduce the duplication of services and free up more time to care for people. All staff will have the skills and knowledge needed to support this new way of working.

How will this benefit staff working in the NHS in Lincolnshire?

Staff from across social care, primary care, community services, secondary care and the third sector will work together to develop a shared culture that encourages effective teamworking. This will enable them to take a more collaborative and flexible approach to care planning, focused on the needs of the person. They will be empowered to drive continuous improvement and feel valued. They will have the skills and knowledge needed for collaborative working, and access to digital care records and the relevant technologies that form the basis of community-based support.