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.
Explore community-based integrated services
- Social prescribing and community-based support: summary guide (NHE 2019)
- Shifting the centre of gravity: making place-based, person-centred health and care a reality (LGA & al. 2018)
- Reimagining community services (King's Fund 2018)
- Primary care home and social care: working together (NAPC 2018)
- Making it real: how to do personalised care and support (TLAP 2018)
- Transforming care and support (SCIE 2018)
- Innovative models of general practice (King's Fund 2018)
- Shifting the balance of care (Nuffield Trust 2017)
- Social work: improving adult mental health (DH 2016)
Practice examples Open
- Bracknell Forest: Changing care and support in the community (NHSE Integrating Better 2019)
- Gloucestershire: Housing and Partnership working (NHSE Integrating Better 2019)
- Mental health and community providers: lessons for integrated care (NHS Confederation 2017)
- Integrated care for older people with frailty: innovative approaches in practice (RCGP & BGS 2016)
- Housing: getting people home from hospital (Housing LIN)
- Integrated care case studies (LGA)
Measuring success Open
- Formal and informal long-term care in the community: interlocking or incoherent systems? (Jornal of Social Policy 2018)
- Stepping up to the place evidence review (ICP 2018)
- Community care for people with complex care needs: bridging the gap between health and social care (IJIC 2017)
- The effectiveness of community-based coordinating interventions in dementia care (BioMed C. 2017)
Latest evidence Open
These are the latest resources from Social Care Online, the UK’s largest database of care knowledge and research.
Learnings from implementing telemonitoring – the LITE study
- Emerald, 2019
Integrated care for frail elderly: a qualitative study of a promising approach in the Netherlands
- International Foundation for Integrated Care, 2019
Challenges to successful community-based integrated approach to dementia: a qualitative study
- Taylor and Francis, 2019
Investing in the enablers of integrated local care
- Social Finance, 2019
Relationship-centered dementia care: insights from a community-based culture change coalition
- Sage, 2019
Specialist community teams for adults with learning disabilities: referrals to a countywide service in England
- Emerald, 2019
Multisectoral mental health networks in Belgium: an example of successful mental health reform through service delivery redesign
- World Health Organization. Regional Office for Europe, 2019
Scaling up community-based models of care in Northern Ireland
- Social Care Institute for Excellence, 2019
Interventions to promote early discharge and avoid inappropriate hospital (re)admission: a systematic review
- Molecular Diversity Preservation International and Multidisciplinary Digital Publishing Institute, 2019
“It’s changed everything”: voices of veterans in the veteran-directed home and community based services program
- Taylor and Francis, 2019
- Learnings from implementing telemonitoring – the LITE study
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.