Community-based integrated services

What is this and how does it work?

One aim of integrated care is to enable people to receive care closer to home, with services focused on keeping them well and avoiding unnecessary hospital care.

Achieving this requires a variety of local services – public, voluntary and private – to work more closely together and in new ways.

When services are designed around the needs of the local population and tailored to the local context and priorities, people and their carers are then able to access much of the care and support they need locally – and in a more seamless way.

Communities are the places where preventive programmes can flourish. Having a broad offer of community services supports people’s self-care and wellbeing, independence and social participation.

For example, appropriate transport, housing, leisure services and voluntary activities have been shown to help people remain active and stay well.

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    Community-based services for integrated care. What is this and how does it work?

    One aim of integrated care is to enable people to receive care closer to home, with services focused on keeping them well and avoiding unnecessary hospital care. Achieving this requires a variety of local services – public, voluntary and private – to work more closely together and in new ways.

    This broad offer of community services supports people's self-care, independence, social participation and wellbeing.

    How do community-based services support integrated care?

    People receiving care and support in the community often have multiple long-term conditions. They rely on a range of services and professionals. Without a wider offer of care and support in the community, people with complex needs are less likely to have their needs met. Transforming community-based services is therefore integral to the delivery of person-centred coordinated care.

    And simply, people tend to fare better when their health care, mental health and social care needs are met in the place they live.

    What do integrated community-based services need to succeed?

    There are some key principles underpinning their successful implementation. These include:

    • making community-based care the focus of the system
    • organising and coordinating care around people's physical health
    • mental health and social needs
    • making the best use of all the community's assets
    • enabling professionals to work together across boundaries
    • building in access to specialist advice and support
    • empowering people with help of families, carers and communities to take control of their own health and care.

    What is the evidence for outcomes and impact?

    The evidence suggests that strengthening community-based services may lead to improvements to the health and wellbeing outcomes of the local population, a reduced demand for intensive hospital, residential and other care and better quality of care and improved satisfaction with the services.

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How do community-based services support integrated care?

People receiving care and support in the community often have multiple long-term conditions and rely on a range of health and care services and professionals.

Evidence suggests that their health and wellbeing outcomes tend to fare better when their healthcare, mental health and social care needs are met in the place they live.

Transforming community-based services is therefore integral to the delivery of person-centred coordinated care. Without a wider offer of care and support in the community, people with complex needs are less likely to have their needs met. They could end up unnecessarily in hospital when their care needs change or require urgent attention.

Two enablers for integrated community services include joint commissioning and the pooling of NHS and local authority budgets. Commissioners have a responsibility for building local capacity to provide care closer to home, including creating opportunities for service innovation. 

Using asset-based approaches to community engagement ensures voluntary services are available to augment the statutory offer. Others approaches include the re-design of care pathways and new delivery models, such as those that bring together primary care, community health and social care and specialist services.

What do integrated community-based services need to succeed?

To be effective, the design and delivery of community-based services need to reflect the key aims of integration, namely to support person-centred practice and service coordination.

The King’s Fund sets out in Reimagining community services the design principles that underpin the successful implementation of integrated community-based services:

  • Organise and coordinate care around people’s needs
  • Understand and respond to people’s physical health, mental health and social needs
  • Make the best use of all the community’s assets to deliver care to meet local needs
  • Enable professionals to work together across boundaries
  • Build in access to specialist advice and support
  • Focus on improving population health and wellbeing
  • Empower people to take control of their own health and care
  • Design delivery models to support and strengthen relational aspects of care
  • Involve families, carers and communities in planning and delivering care
  • Make community-based care the focus of the system

What is the evidence for outcomes and impact?

The evidence suggests that strengthening the design and delivery of integrated community-based service may help:

  • improve the health and wellbeing outcomes of the local population
  • moderate, and in some cases reduce, demand for intensive hospital, residential and other substitute care
  • improve the quality of care and people satisfaction with the services, particularly for people with complex needs
  • reduce duplication of services and improve resource allocation.