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.