Integrated Care Communities (ICCs)
Developing joined up health & care in communities
• Integrated Care Communities (ICCs) is one of the terms being used nationally and locally to describe the ambition to join up health and care services in a given community, tailored to the needs of the local population.
• An ICC will see health and social care professionals, GPs, the voluntary sector and the community working as one team within one system to support the health and care needs of population it serves. It will focus on helping the population to manage long term health conditions and improve access to information about healthier lifestyles locally.
• Evidence shows that the most successful Integrated Care Communities will reduce the overall number of people who need to be cared for in hospital and improve the health and wellbeing of communities.
• The evidence is supported locally by early work in Millom that has shown that providing more care outside hospital, particularly for the frail and elderly, has led to faster recovery times as well as allowing us to treat more people.
• The leaders from all partners across the system including Cumbria Partnership NHS Foundation Trust, North Cumbria University Hospitals Trust, NHS Cumbria Clinical Commissioning Group, Cumbria County Council, & GP practices have made a firm commitment to develop integrated care communities and have started work together to provide better support to teams locally, many of whom are already using principles of integrated working in providing care.
• West, North & East Cumbria has been divided into eight Integrated Care Communities to align with clusters of GP practices and their registered populations. Three Integrated Care Communities managers have been appointed to work across West, North & East Cumbria to support the development of ICC’s with a specific focus on 3 ‘Early Implementer areas’ - Workington, Cockermouth & Maryport and Eden.
• This following animation of ‘Sam’s Story’ describes the thinking behind the Integrated Care Communities.
What will an ICC look like?
ICCs have been described as:
‘A defined community where community services, general practice, social care and groups come together to provide both person centred co-ordinated care and organised approaches to improving the population’s health’.
But what does this really mean in practice? It means:
• Health and Social Care organisations breaking down barriers to enable staff to work together to effectively deliver locally based care
• Within an ICC creating one multi professional ‘ICC community team’ with a shared approach to referral, assessment, care planning and case management and care co-ordination
• Aligning these teams with clusters of GP practices and their registered populations.
• Staff from different professions or organisations working together to meet the needs of the individual who needs care rather than referring between one another
• Providing a ‘rapid response’ function so that when there is a crisis individuals are supported to remain in their own home and that when they are admitted they can return home as soon as possible.
• Pooling data and knowledge of all those working in the ICC to identify those most in need of care or at risk of needing care and working together to meet these needs: a more proactive approach to care.
• Thinking about the public health needs of the ICC population and working with partner agencies such as third sector groups or district councils, to meet these specific needs.
• Enabling individuals to manage their own health
• Aligning budgets, thinking about how we get better value for money for system as a whole and stopping the ‘whose budget is it?’ debate getting in the way of delivering what is right for the individual who needs care.
• Aligning these teams with clusters of GP practices and their registered populations.
What are the benefits of ICCs?
Benefits for service users, carers and communities
• Care and support is delivered in the most appropriate setting
• It will reduce the amount of times you need to keep explaining your story to different people. We know this causes frustration and anxiety.
• We are working to ensure you are not passed around from one team to another
• People are given information and support to self-manage their long term conditions
• More care and support is accessed locally from third sector and communities
• Simplified pathways improve patient outcomes and experience and reduce variation in the quality of services received
• More empowered and involved individuals:
- “I can plan my care with people who work together to understand me and
- my carer(s), allow me control, and bring together services to achieve
- the outcomes important to me.” National Voices.
Benefits for staff
• Improved morale/job satisfaction
• Fewer hand offs and less duplication, freeing up valuable time
• Opportunity to share skills and experience
• Better working environment can lead to improved recruitment and retention of staff
• Reduced bureaucracy
Benefits for the system
• Getting more from our existing resources
• Reduced waste through avoidance of duplication
• Reduction of hospital admissions and reduced length of stay
• Improved self-management of long term conditions
• Fewer residential /nursing home placements
• Greater independence post discharge
How will ICCs be implemented in West, North and East Cumbria
The Chief Executives of the local organisations sit on a ‘Delivery Board’ which will oversee an ICC Steering Group responsible for the implementation of ICCs in WNE Cumbria.
There will be 8 ICCs covering populations of between 30,000 and 60,000.
Three ‘Early Adopter’ sites Cockermouth &Maryport , Eden and Workington have been identified and in July 2016 3 ICC Managers were seconded from existing roles within CPFT and CCG to support the development of ICCs over the next 12 months. Managers will be recruited for Keswick & Solway ICC and Carlisle Healthcare ICC in Autumn 2016 with other ICCs coming on line in April 2017.
The managers will work locally with a small multi-agency ‘leadership group’ advised by a wider ICC ‘reference group’ comprising local stakeholders including third sector groups and public representatives which will determine the ways in which ICC team staff work.
So are they all the same?
Yes and No! Each ICC will have a defined set of functions and they will be expected to deliver the same ultimate outcomes and meet the same standards for delivering high quality and safe care. But, each ICC will be a different size, have different historic provision and different public health needs so there will be variability in how they go about the delivery of some services. A key aim of the ICC ‘one-team’ model is to allow frontline staff to collaborate and innovate to provide the best care possible based on their understanding of the needs of their local population.
Why do we need Integrated Care Communities?
The needs of the people of West, North and East Cumbria people are changing with a growing elderly population and increasing numbers of people living with long term conditions. Health and social care services need to adapt to meet the changing needs of our population and to improve people’s experience of services.
Health services provided by the NHS and Social Care Services provided by the Council do not always join up in the way that our residents need and expect them to. Individually, health and social care services are doing a good job but people’s experience of the system as a whole is that it is often confusing and care is disjointed.
Existing services tend to focus of treating ill health rather than supporting people to stay well. Too many people are in hospital or in residential care when they could be cared for at home if the right support was available. Our residents often feel disempowered by a system that deals with problems after they arise and would rather be supported to make their own choices about how services can help them to remain well and independent.
Our community is already working in an integrated way, what are you planning to do differently?
For many years, health and social care professionals have been working more closely together but this has often occurred on a fragmented basis and dependent on historic investments or only in particular geographies. The way our health and social care system has been set up has often hindered rather than helped professionals to provide joined up person-centred care.
Other communities do need support to develop closer links and the support and commitment of all of the partners involved to work together with one budget is a key step in working together more effectively for the community.
How will the development of Integrated Care Communities be funded?
In each of the Integrated Care Communities, the existing budgets of health and social care providers will be pooled. In addition we are proposing to re-invest half of the savings that are made as part of the overall clinical strategy for West, North and East Cumbria to develop Integrated Care Communities.
What about services that can't be delivered locally?
Services that need to operate on a larger footprint than an ICC will sit at a ‘Network’ level (East or West Cumbria). It is anticipated that Network Co-ordination Hubs will link with the ICC Hubs to help speed up the discharge process, prevent inappropriate acute admissions and allow for smooth referral to and from specialist services.
It is acknowledged that there will need to be a phased approach to teams working within an ICC framework, i.e. community nursing/community therapy teams but other roles will be incorporated over time as it will take time to adapt current methods of working to an alternative model of integration.