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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.

Multidisciplinary teams

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

Assessment and care planning

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

Community-based integrated services

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

Care and support in crisis

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

Transitions of care

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