Integrated Care “ Building on existing care through more joined up approach” Dr Katie Coleman Joint (Clinical) Vice Chair ICCG 1

Islington has the lowest life expectancy for men in London and fourth lowest for women. Nearly half of all the deaths in the borough are in people under the age of 75 Approximately 28,000 adults between years are diagnosed with a long term condition, conditions that people live with for the long term such as diabetes and COPD A third have more than one condition To ensure long term conditions are well managed at an early stage by a GP, rather than at a late stage by the hospital Why Integrated Care? 2

When health and social care professionals work together, we can ensure that care is integrated and that people live healthy, fulfilling lives Services will work with patients and families/carers to help you manage your health The team will help you to develop a personal care plan which will record what your specific needs are The care plan will be shared by everyone who is involved in the management of your health, so hopefully improving communication and reducing frustrations of the patient journey, particularly at the interface between health and social care What is Integrated Care? 3

4 Components to Integrated Care

5 Components to Integrated Care (2) Many Patients need the coordinated input of different professionals, The Integrated Care Programme aims to accurately identify these people Some patients will benefit from having everyone getting together to coordinate things better Every so often we will want to check on how well we are doing

Be in control of their condition Respect and recognition of their everyday effort to self care Be part of the decision making process Targets will be their choice – achievable + specific Better understanding of their condition Encourages partnership in decision making Care Planning - benefits to patients include 6

Information systems are not joined up at present But nearly all the GPs in Islington use the same system All professionals should have access to the care record – so we will need to have explicit agreement between providers Above all, we need to have your verbal and written consent Having a shared information system for care planning will ensure better care delivery co-ordinated through primary care 7 Information Sharing

Sub-localities Key feature of having groups of practices in sub-locality: Wrap community services round them such as name DN team, Social worker, community matron etc Case conferencing for a small number of high risk complex patients with all health care professionals including acute specialist Key feature of having groups of practices in sub-locality: Wrap community services round them such as name DN team, Social worker, community matron etc Case conferencing for a small number of high risk complex patients with all health care professionals including acute specialist 8

What would a joined up/integrated service look like for you? What services might you think we need to ensure better management of patients with Long term conditions? Are there any concerns with having your information records shared with a range of professionals with your consent? What self care programmes/behavioural support would you like to see in Islington? Following discussion on each area – what are the three most priorities for your group? Group Work 9