York Integrated Care Team
Scheme
Who?
Vale of York clinical commissioning group (CCG)
York City
What
A multidisciplinary team made up of:
- nurses (including mental health and learning disability nurses), GPs, occupational therapists, urgent care practitioners, care workers, care coordinators, administrators
Why?
The scheme was set up to:
- reduce avoidable hospital admissions
- expedite safe discharge from hospital
- enable patients to remain independent longer
When?
- May 2014 – trial with 55,000 patients
- January 2015 – following the success of the trial, the scheme was expanded to cover four York-based practices totalling a population of 130,000 patients
How?
The team supports 11 GP practices and works across three integrated workstreams:
- avoiding admissions team
- complex care – care homes
- community carers service.
Challenges
- Engagement with other services – people were sceptical about the integrated care team remit.
- Recruitment – it was hard to find enough people with the appropriate skills when the team was first set up.
Impact
- Positive patient feedback – all respondents (43) to a patient feedback survey said that they were very happy with the York Integrated Care Team service.
- Positive staff feedback.
Case study
Mrs P, a patient on the case management register, was feeling unwell and causing her daughter concern. The daughter called the single contact number and a coordinator passed the case on to a nurse.