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What is integrated care?

Integrated care is where different organisations work together for the sole purpose of providing the very best support for an individual. Rather than working to different support plans and not communicating with one another, integrated care aims to put the individual at the centre of their care plan, with different professionals who are involved in their care working seamlessly together to achieve the same outcomes.

The main aim of integrated care is to provide person-centred support that is joined up in its approach, so that the individual feels valued, listened to and that all of their needs – physical, mental and emotional – are adhered to.

What is an integrated care organisation?

An integrated care organisation is any professional body that is involved with an individual’s integrated care plan. This could be from either the NHS or a private health provider, the local council or charities. Here are some examples of individuals that may be involved in an integrated care plan:

  • GP or district nurse Care assistants Kate and Amy
  • Social worker
  • Physiotherapist
  • Occupational therapist
  • Carer from a private home care provider, such as Helping Hands
  • Local charity, such as Age UK
  • Community mental health team
  • Housing support officer

The above are just some people that may be involved in one person’s integrated care plan, enabling all services to work cohesively together to achieve the best outcomes for that individual. Those involved with someone’s care may change as their needs alter – for example, if someone is recovering from a serious illness that has affected their mobility, they may need round-clock-care and regular monitoring by a district nurse to begin with, with additional help from a physiotherapist to get them mobile again. However, as they start to get better, their care hours may reduce, and they may only need check ups from their GP once a week. This allows for fluidity between the different services that someone may require, giving them the most holistic care to suit them.

What is an Integrated Care Pathway (ICP)?

An Integrated Care Pathway (ICP) is essentially a detailed care plan that describes the individual’s physical, clinical and emotional needs, and setting out the necessary steps to take in order to care for them in the best way possible for the individual. ICPs should be easy to understand for both the professionals and the individual, allowing for any issues that need to be discussed being dealt with at the earliest stage. What’s important about an ICP is that the timeframe given for care and therapy to take place is suitable for the individual and is something that is achievable; knowing when and where things are going to happen can alleviate lots of worry and anxiety for the individual and their families, so having a plan in place can really help with mentally preparing and processing their care.

The aim of an ICP is to have the right professionals in place at the right time, working together to achieve the same set of outcomes for the individual. Whether they work for the local council or NHS should make no difference; they are ultimately working collaboratively to integrate both health and social care for the same individual, putting that person’s health and wellbeing at the forefront of everything they do.

Why is care joining up?

Care is joining up for two key reasons: to enable different health care teams to work together more closely and for the individual to receive care that caters for all of their needs from one plan, rather than lots of different care plans. When any decisions are made, the multi-disciplinary team – that is everyone involved in that person’s care, including the individual where possible – meet to decide on the next step of action. For example, if someone is being discharged from hospital after a serious injury, everyone will meet to decide on a discharge plan that incorporates their medical care, health care, social needs and mental wellbeing. That way, they can ensure that the individual receives specialist care suitable for all of their requirements that everyone has agreed upon.

Joined up care is particularly important for someone with complex care needs who require several different specialists involved i.e. different consultants. Previously, individuals who had lots of care needs described how they grew tired and frustrated with having to repeat themselves to different health care professionals, wanting them to have an understanding of their ongoing needs from the outset rather than catching up every time they saw them. Integrated care now showcases how a variety of different professionals can work together, with the individual in question at the centre, to all create a comprehensive plan to better the individual and their wellbeing.

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