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Integrated Care

Our strate­gic inten­tion is to trans­form ser­vices to sup­port the peo­ple of East Lan­cashire to live safely and live well. Inte­grated care is a means by which we can co-ordinate care around the needs of indi­vid­u­als in our com­mu­nity to enable our goal to be realised. Suc­cess­ful deliv­ery of the inte­grated care agenda will ensure that the right care is offered to peo­ple in the right place at the right time. Health and social care ser­vices in East Lan­cashire are already work­ing more closely together to meet the needs of patients and carers. The CCG and Lan­cashire County Coun­cil is com­mit­ted to putting the patients, their car­ers and fam­i­lies first and mak­ing sure that it is more straight­for­ward to access sup­port and co-ordinate that support. We are work­ing to intro­duce multi-disciplinary inte­grated neigh­bour­hood teams to make sure that sup­port is ‘joined up’. Where peo­ple have a num­ber of health and social care needs, the aim is to pro­vide one con­tact per­son to make things eas­ier for them. That per­son will help to plan and co-ordinate ser­vices on their behalf and based on their needs. This is a major change for the ‘sys­tem’ and will take some time to imple­ment fully. We will first focus on older peo­ple who are frail, peo­ple with long-term con­di­tions and those who are vulnerable. The timescales for other areas are:

  • 2013–15 Long term conditions/frail elderly/end of life/ high inten­sity users
  • 2014–16 Men­tal health, sub­stance mis­use and learn­ing disabilities
  • 2015–17 Chil­dren and young peo­ple – includ­ing com­plex needs, early help and uni­ver­sal ser­vice provision.

Although we have been work­ing on this for some time and have some exam­ples, such as that below, the money from the Bet­ter Care Fund — £26m for East Lan­cashire – will be used to accel­er­ate this work in the run up to and dur­ing 2015/16. Exam­ple: The Inter­me­di­ate Care Appli­ca­tion Team (ICAT) is a team of pro­fes­sional health and social ser­vice staff who assess the needs of peo­ple , either liv­ing in the com­mu­nity or being dis­charged from hos­pi­tal, who need sup­port and then make sure that a pack­age of care is deliv­ered to sup­port the per­son and their carers/family. Harry is a 92-year-old man with a diag­no­sis of early-stage demen­tia who has pre­vi­ously been inde­pen­dent. Fol­low­ing a stay in hos­pi­tal, he realised he was not cop­ing very well at home and after sev­eral falls, he became depressed and started to stay in bed. His fam­ily con­tacted social ser­vices who referred him to the ICAT team. They sug­gested a tem­po­rary period of res­i­den­tial reha­bil­i­ta­tion, focus­ing on increas­ing his con­fi­dence, address­ing his depres­sion, improv­ing his mobil­ity and increas­ing his nutri­tional intake. When he left rehab, his sup­port included med­ica­tion man­age­ment, vis­its from a vol­un­teer befriend­ing ser­vice and links to com­mu­nity activ­i­ties. He is now back at home and feel­ing and cop­ing much better.