We are working together to provide you with more local and personalised services. This guide explains these services.
Patients and carers have told us that health and social care services could be easier to use and better coordinated or “joined-up”. Patients say that they often repeat the same information to different professionals which can be frustrating.
Our aim is to improve the coordination between different health and social care services to make it easier for patients to use and ensure that patients only need to tell their story once.
Integrated Neighbourhood Team
To help you, we have set up a way of working called The Integrated Neighbourhood Team. By doing this we aim to improve coordination and communication between health and social care (including GPs) and you, your family and carers. We also aim to provide the services you need in your community when you need them.
To support this way of working, your GP has been asked to share access to your medical records when appropriate with health and social care organisations within your local neighbourhood team. We do this to help ensure that patients get the right treatment and services that they need.
Who is part of the Integrated Neighbourhood Team?
The members of the local health and social care services referred to as the Integrated Neighbourhood Team.
- Local Primary Care Team including GPs and Practice Nurses.
- Nursing services.
- Therapy services
- Social Workers
- Mental Health Teams
- Intensive Home Support Services
There may also be involvement from local community groups in your area and organisations such as Age UK, Carers Link, local hospices and the North West Ambulance Service.
What will happen if you are referred to the Integrated Neighbourhood Team (INT)?
If a health professional or representative from a social care organisation feels you would benefit from the support of the INT, they will discuss this with you and gain consent to refer to your local INT. In some cases where consent cannot be gained it may be appropriate to discuss an individual’s needs in their best interest.
Following a referral, you or a family member may be contacted by the Clinical Coordinator for further information.
Regular meetings are held in your area to discuss your individual health and well being needs while you are cared for by the INT.
Whilst under the care of the INT, your case manager will be the INT Clinical Coordinator or a member of the INT Team, giving you the opportunity to have one point of contact and will work with you to develop a care plan to address your individual needs. We will support you to manage any conditions/concerns you may have.
Your case manager will regularly review your care plan while you are an INT patient and communicate with other people involved in your care and provide regular updates to your GP to make sure everyone is working together for you.
On discharge from the INT it may be necessary to allocate a new case manager who will review your health and social care needs at regular intervals as agreed with yourself.