Wrapping care around the patient: the power of integrated care

Health and care professionals are working in more flexible and dynamic ways to provide care that’s wrapped around patients in Doncaster.

As part of Integrated Care week, Integrated Care Systems (ICS) across the country are demonstrating how working together can better join up services and organisations, break down barriers. Doncaster is part of the South Yorkshire and Bassetlaw ICS and a number of projects and programmes are taking place across the borough, demonstrating the importance and benefits of working together.

The frailty project in Thorne is uniting local health and care staff to work much more closely together, to quickly identify issues, concerns and opportunities to improve health outcomes and experiences of local people.

Teams working in Thorne have been coordinating a single, holistic assessment based on what is important to the person and their strengths. Trialling a jointly created care plan means that health and care professionals can identify and address actual and potential issues that may impact on an individual’s health. This could be anything from the risk of falling, mobility, pain control, problems with activities of daily living, managing anxiety and depression.

An example of how integrated care has multiple benefits for patients is the wrap around support Elisabeth is receiving to address a number of ongoing health issues.

Elisabeth has a history of painful Rheumatoid Arthritis, decreasing mobility, and uses various different medication to control pain. Elizabeth required two carers and consideration was being given to install a ceiling track hoist or admission into a care home.

A multi-disciplinary team undertook a coordinated assessment of Elisabeth’s health and wellbeing. So instead of multiple assessments taking place at different times and by different organisations, Elisabeth’s needs and future aspirations were reviewed by a team, working and talking to each other.

As a result, the team listened to Elisabeth’s wishes and aspirations. To help achieve these, a full medication review took place, resulting in reduced and more appropriate medicines, supporting improved pain management. The team also identified a missed opportunity for a physiotherapy assessment, ensuring appropriate and tailored intervention could be put in place to help Elisabeth maintain her independence. The next day Elisabeth walked with her frame for the first time in a number of months.

Jo Forrestall, Head of Strategy & Delivery for Intermediate Care, NHS Doncaster Clinical Commissioning Group said: “The frailty programme is working at pace to develop an integrated model of care, focussing on the needs of older people that need help and support to maintain and improve their health, wellbeing and independence.

“This approach means that we listen more the patients’ story, they tell this only once and we address all their concerns including the wider determinants of health.

“The frailty programme is still in its infancy, but it is pleasing to see how this new approach is supporting and of benefit to patients in many different ways.”

Rachael Webb, Clinical Leadership Fellow, specialising in the Integration of Elderly Care Services at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust said: “People living with frailty and their family carers often experience deteriorating physical and mental health, often with one or more long-term conditions, sometimes including dementia.

“Individuals with frailty are likely to be coming towards, or in the last stage of their lives and can often experience crises in their physical and mental health, resulting in frequent attendance at the Emergency Department or in unplanned, emergency admissions to hospital.

“This is one of the reasons why the frailty programme is so important – to ensure health issues and concerns are identified and addressed as quickly as possible, preventing hospital admission.”

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