An integrated network is a team of health and social care practitioners who work together in a joined up way to support patients and service users with the greatest needs or most complex clinical or social problems. Integrated networks, one of Islington’s the key integrated care projects, play a key role in enabling us to deliver on our vision of ‘working together to deliver better care with the people of Islington’.
Each network is based around a small group of GP surgeries. They meet weekly or fortnightly and discuss the most challenging issues faced by patients and service users registered at those surgeries. Networks typically include a GP from each member practice, a senior social worker, a community matron, a mental health practitioner, a clinical representative from the local hospital and a health navigator. This ensures networks have representation from all the key health and social care providers.
The team together agrees how to provide support for that person, creating a joined-up plan, which is reviewed regularly until all the issues have been resolved.
Interventions agreed in the plan help:
- reduce the likelihood of a patient having an unplanned admission to hospital or long-term care
- support their existing community care
- introduce a new approach to solving any previously intractable long-term problems
Which patients and service users get this extra support?
Members of the network are able to raise the case of any individual under their care. The team can also draw on clinical data which flags up individuals who might benefit most from extra support. Networks typically help the 5% of patients and service users with the most complex care needs, and those at most risk of unplanned hospital admission or admission to long-term care.
What are the benefits?
Patients and service users benefit from a more joined-up, coordinated approach across the health and care services involved in their care, resulting in real improvements to their care and overall wellbeing. Evidence and feedback from two pilot sites in 2015 was encouraging. This led to the roll-out of networks across Islington in 2016. There are now 12 networks in place. An evaluation in September 2017 showed that networks have led to a significant reduction in A&E attendances and admissions.
Click here to watch a video of health and social care professionals and a patient talk about the benefits of integrated care.