York Integrated Care Team
Vale of York clinical commissioning group (CCG)
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
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).
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.