Activities to achieve integrated care

The activities of integrated care describe the interventions and practice-focused approaches that deliver person-centred coordinated care.

They range from proactive and preventive management of care needs to effective behaviours of multidisciplinary teams, joint care plans, community-based services and care support in crisis and during transitions.

Prevention and self-care

Enabling people to maintain or regain independence and improve their quality of life.

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Multidisciplinary teams

Bringing together the expertise and skills of different professionals to assess, plan and manage care jointly.

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Joint needs assessment and care planning

Multidisciplinary teams working with people who use services and their carers to produce joint needs assessments.

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Community-based integrated services

Enabling people to receive care closer to home, with services focused on keeping them well.

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Care and support in crisis

Providing timely access to advice and treatment to prevent an escalation of needs that require emergency care.

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Transitions of care

Smooth transitions of care ensuring people receive the support they require in the right place and at the right time.

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