Logic model for integrated care
Published March 2024
Overview of logic model
The logic model for integrated care describes what good looks like, providing a visual depiction of how a fully integrated health and care system might be structured and function, and the outcomes and benefits it should deliver for those who use services and their carers. It describes:
- the enablers of integration
- the key activities of integrated care
- the outcomes for people who use services, for the integrated services and for the wider health and care system
- the long-term impacts and benefits.
Activities
Outcomes
Impact
Stakeholders who contributed to developing the logic model suggested it would be a useful tool for local planning and performance monitoring. We encourage you to use the logic model for this purpose, and to provide us with your feedback.
Download the logic model (enablers, activities, outcomes and impact)
This image provides the overall structure of the logic model and gives a visual representation of how the different elements of the logic model (enablers and activities) connect.
The enablers and activities are set out underneath in more detail.
Enablers and activities
The contextual factors that create the pre-conditions for integrated care.
- Establishing a system-wide vision for integration and innovation: Foster a culture of cross-sector collaboration, build trusting relationships, and define clear, shared outcomes to drive integration and innovation across the entire system.
- Commitment to local leadership: Support local autonomy, recognising the crucial roles of places, neighbourhoods, and wider communities. Simultaneously, ensure system-wide cohesion to harmonise efforts and outcomes.
- Transparent regulatory and accountability framework: Implement a regulatory and accountability approach that is transparent, enabling, and geared towards delivering high-quality, innovative services. This approach promotes openness and facilitates the achievement of shared goals.
- Empowering Individuals and Carers with Choice and Control: Foster empowerment through strengths- and asset-based approaches, shared decision-making, and co-production, allowing individuals and their carers to have greater choice and control over their wellbeing.
- Collaborative Partnerships for Person-Centred Care: Forge collaborative partnerships with communities, voluntary organisations, housing services, and the independent sector to deliver resilient, person-centred care.
- Holistic Cross-Sector Approach to Care and Support: Adopt a holistic, cross-sector approach to care and support that encompasses social care, physical and mental health care, housing, community resources, and non-clinical support. By integrating these elements, a more comprehensive and effective support system can be established.
- Empowering Individuals and Carers with Choice and Control: Foster empowerment through strengths- and asset-based approaches, shared decision-making, and co-production, allowing individuals and their carers to have greater choice and control over their wellbeing.
- Collaborative partnerships for person-centred care: Forge collaborative partnerships with communities, voluntary organisations, housing services, and the independent sector to deliver resilient, person-centred care.
- Holistic cross-sector approach to care and support: Adopt a holistic, cross-sector approach to care and support that encompasses social care, physical and mental health care, housing, community resources, and non-clinical support. By integrating these elements, a more comprehensive and effective support system can be established.
- Achieving a flexible workforce: Develop a fully integrated, adaptable, and competent workforce capable of providing care coordination and person-centred services across boundaries and sectors.
- Cross-sector collaborative strategies: Achieve this flexible workforce through cross-sector, system-wide collaborative strategies for workforce planning, recruitment, employment, and training.
- Managing the workforce together: Implement key measures that include optimising skill-mix and upskilling, redistributing tasks and roles across various services and sectors, considering co-location or relocation, and introducing innovative roles such as care coordinators.
- Empowering professionals with shared access to digital records: Enable professionals across health and social care settings to access shared records, fostering collaborative and well-informed decision-making in the delivery of care.
- Encouraging user access to personal data: Enable users/patients/those that draw on care and support to access their records, promoting transparency and active involvement in their care. This empowers individuals to be active participants in their healthcare journey.
- Facilitating data collection for research and policy: Promote the collection and utilisation of data for research purposes, contributing to evidence-based policy and practices. This approach supports tailored interventions based on comprehensive and up-to-date information.
- Collaborative and integrated service planning: Implement a collaborative and integrated approach in planning, procuring, and delivering services across the health and social care sectors, as well as the broader community services encompassing both public and voluntary sectors.
- Inclusive, participatory decision-making: Involve individuals with lived experiences, communities, local providers, and professionals in setting priorities, designing pathways tailored to local needs, and delivering services.
- Effective budget pooling: Optimise the pooling or alignment of budgets to ensure service coordination and transparent funding distribution. Ensure care teams have ready access to resources through joint budgets and contracts. This facilitates the provision of integrated care and support packages tailored to individual needs.
- Establishing a resilient and diverse network: Foster a robust, resilient, and diverse network of health and care service providers with the capability to consistently and reliably deliver high-quality care.
- Promoting collaboration and integration: Encourage strong collaboration and integration among different providers across sectors and services, ensuring a seamless continuum of care. Examples include provider collaboratives aimed at enhancing coordination.
- Commitment to innovation and adaptability: Demonstrate a clear commitment to innovation and adaptability by embracing new technologies, care models, and best practices. This proactive approach ensures the incorporation of cutting-edge solutions for improved patient outcomes and service efficiency.
The types of interventions and services that create integration, and the primary settings where integration occurs.
- Promoting independence through preventative approaches: Implementing preventative approaches aimed at promoting individuals’ independence, with the goal of delaying or avoiding declines in wellbeing due to illness, disability, and/or ageing. The objective is to reduce the likelihood of individuals experiencing crises in their health and/or social situations. Emphasis on prevention through supported self-care, and building personal strengths and community assets.
- Comprehensive prevention services: Prevention services encompass a range of activities, including facilitating access to information, skills, and self-care resources; creating safe and enabling living environments through adapted housing and physical aids; using digital technologies to support self-management of conditions and maintain independence; and developing a physical and social environment through which people can access community-based resources and support and engage in wider society.
- Multidisciplinary teams (MDTs) and interprofessional, cross-sector collaboration: Ensuring that individuals receive coordinated and personalised care, regardless of their location, is made possible through MDTs and interprofessional, cross-sector collaboration.
- Key components of MDTs: Key components of a multidisciplinary approach include an identified manager or practice leader responsible for facilitating the team’s overall function; joint meetings to share insights and concerns; a shared digital record of all contacts, assessments and interventions of team members with an individual and their family. A key worker system is established, coordinating care for those with complex support packages under the guidance of a named team member. The team composition reflects the diversity of professions and disciplines, ensuring alignment with the needs of the target population.
- Care coordination through integrated care assessment and planning: Joint needs assessments, integrated care planning and management and discharge assessments play a crucial role in improving care coordination, preventing duplication across professionals and services, and fostering better integration between formal care, informal networks, and community resources.
- Collaborative development of shared care plans: Shared care plans are developed and implemented collaboratively, involving both the individual and their family. This ensures a holistic and inclusive approach to care.
- Personalised care with support for personal budgets: Care assessment, planning, and delivery are personalised, tailored to individual needs. Additionally, where appropriate, the process supports the use of personal budgets and personalised commissioning arrangements, ensuring flexibility and responsiveness to individual preferences and requirements.
- Coordinated care closer to home: Community-based health and social care services – primarily delivered at the place and neighbourhood levels, and often via primary care networks – comprise a diverse array of professions and services, including primary care, social work and social care services, nursing, occupational therapy, reablement services, pharmacists, and intermediate care facilities.
- Flexible settings for community care delivery: These services operate not only within individuals’ homes but also extend to communal settings such as residential care and nursing homes, as well as supported living environments.
- Innovative integrated pathways: The introduction of new integrated pathways, facilitated by shared-care agreements, allows individuals residing in the community to access specialist care. This is made possible through collaborative efforts between hospital-based clinicians, general practitioners, and community-based teams, ensuring a comprehensive and coordinated approach to healthcare.
- Comprehensive crisis management and rapid response services: Implementing a composite approach to crisis management, featuring rapid response services such as a 24/7 single point of access, urgent community response teams, ambulance interface, mental health crisis services, virtual wards, and home treatment.
- Innovative collaborative models for crisis care delivery: Fostering innovative collaborative models that leverage specialised skills and technology, bringing together health and social care professionals along with representatives from sectors such as housing and police.
- Timely and integrated crisis care delivery: Ensuring the delivery of the right care at the right time and in the right place. Integrated care and support during a crisis contribute to the reduction of preventable hospital admissions and long-term care, promoting a more effective and responsive health and care system.
- Coordinated transitions: Care transitions involve individuals navigating through the boundaries of existing care provisions. Well-managed care transitions are those carefully planned before the move, involving the individual and, when appropriate, family carers in decision-making. Coordination is centred around the specific preferences and needs of the individual.
- Ensuring safe and timely transitions: Interventions supporting safe and timely transitions primarily aim to ensure individuals continue to access the support they need. This becomes particularly critical when individuals no longer require hospital care and need referral to community health services or social care. An integrated approach to transitions of care addresses the needs of various groups, including older and frail individuals, those with long-term and complex needs, individuals with mental health challenges, and those requiring additional short-term support in the community to enhance their independence.
- Recognising the vital role of carers: Carers play a critical and demanding role in the delivery and success of integrated, person-centred services. They need integrated, high-quality, responsive support.
- Key components of integrated carer support: These encompass the comprehensive assessment of carer needs, capabilities, challenges, and wellbeing; collaborative care planning, ensuring that carers’ insights and preferences help shape the care strategy; seamless communication and information exchange with professionals and services; offering essential respite care to provide carers with the necessary breaks and support; connecting carers with local community resources, support groups, and services that can provide additional assistance and a sense of community.
Systems
- Integrated care promotes efficiency by providing best value services in the right setting, eliminating service duplication, improving services user flow and reducing delays.
- Integrated care shifts service capacity and resources from higher cost hospital settings to community settings.
- The system enables personalisation by supporting personal budgets and integrated commissioning where appropriate.
Services
- The integrated care delivery model is proactive in identifying and addressing care needs as well as responsive to urgent needs, with more services provided in primary and community care settings.
- Professionals work collaboratively to coordinate care through ready access to shared user records, joint care management protocols and agreed integrated care pathways.
- Integrated teams are readily able to access joint resources to meet the needs of service users.
- Transfers of care between care settings are readily managed without delays.
People's experiences
- My care and support help me to live the life I want to the best of my ability and to remain a contributing member of my community.
- I am as involved in discussions and decisions about my care, support and treatment as I want to be. I have the information, and support to use it, that I need to make decisions and choices about my care and support.
- When I move between services or care settings, there is a plan in place for what happens next.
- Carers report they feel supported and have a good quality of life.