York Integrated Care Team



Vale of York clinical commissioning group (CCG)

York City


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
  • the person’s family and friends
  • secondary care and social care colleagues
  • the ambulance service
  • third-sector colleagues
  • everyone!


The scheme was set up to:

  • reduce avoidable hospital admissions
  • expedite safe discharge from hospital
  • enable patients to remain independent longer
  • deliver person-centred care
  • deliver support In the ‘right place at the right time’.


  • 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
  • September 2015 – start of rapid expansion to cover all City of York practices (207,000 patients).


The team supports 11 GP practices and works across three integrated workstreams:

  • avoiding admissions team
  • complex care – care homes
  • community carers service.

The focus is on the person.

  • There is one telephone contact point for all health and social care services and fast response times to calls.
  • The person only has to tell their story once.
  • A named nurse acts as facilitator within the local system.

The integrated approach enables:

  • access to multiple clinical and social care systems: SystemOne, EMIS and Core Patient Database, Mosaic
  • streamlined support to care homes from primary care making best use of time and resources, freeing up capacity for more complex case management and support
  • connecting with communities and making third-sector referrals
  • sharing knowledge and mentoring students
  • upskilling care home staff
  • reviewing admissions and discharges for all patients on the register at a daily multidisciplinary team meeting
  • Pre-emptive multidisciplinary teams: all discharged patients on the register are contacted within 72 working hours.


  • 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.
  • Data-sharing – improvements have been made in data-sharing but social care teams still cannot access clinical data.
  • Workspace – finding adequate space to grow the team was difficult.


  • 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.
  • Improved integration and referrals to third sector.
  • Improved integration with secondary care services and social services through multidisciplinary team working.
  • Slight increase in hospital discharges facilitated through ‘One Team’ pathway.
  • Reduced numbers of excess bed days (XS bed days).
  • Initially reduced number non-elective admissions (due to coding changes of ambulatory care conditions, there has been a significant increase in zero length of stay admissions, affecting the overall total).
  • Reduced lengths of stay over four days (LOS>4 days).

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.

The nurse visited Mrs P at home to assess her condition and diagnosed a urinary tract infection (UTI). The nurse then contacted a GP for a prescription of antibiotics. This integrated approach meant that Mrs P’s daughter was able to pick up the antibiotics locally within three hours of first making contact.

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