Partnership moves integrated care for the elderly into the community

A new partnership is set to develop an integrated health management service for older people living in London’s Islington area, bringing care into the community.

University College London Hospitals, working with The Whittington Hospital and other chief care providers in the borough, has been consigned by Islington’s Clinical Commissioning Group to form the Integrated Community Ageing Team offering a multidisciplinary service to older residents.

The new facility, which trialled in mid-October, includes an initial two-hour assessment to evaluate physical, mental and social wellbeing, which is carried out in the patient’s own home.

Bringing a thorough health service away from acute settings to home visits will be of particular benefit to patients who may be experiencing difficulties with mobility. At home, getting around is largely improved with stair lifts, but for many elderly patients, visiting the GP’s offices can be challenging.

Lead nurse for the Integrated Community Ageing Team (ICAT), Katrina Clapham, explains: “It’s all about what’s important to the patient. The focus is always on them and what they want.”

Analysing the results of the comprehensive health check, a programme of any necessary support or intervention is prepared by the members of the team. Depending on the individual’s needs, this could include pharmacy or occupational therapy services or physiotherapy.

The scheme is expected to be especially important in improving frailty care in the area and where patients experience issues with balance and mobility hindering their ability to get out and socialise, ICAT will work to address this with local representatives of the charity Age UK.

ICAT’s clinical lead, Dr Ruth Law, said: "We now have the resources to actively help and manage care for frail older people in the community, with much greater interaction between hospital and community teams.

“If patients do need to come into hospital those links with community colleagues mean we're benefiting from greater awareness and knowledge of patients, and assurance around how their care is continued after discharge."

The number of people in the area being cared for through this community initiative has meant that fewer cases are referred to the local hospitals and patients are able to maintain a level of comfort and independence by staying in their own homes.

So far the integrated care scheme has had positive feedback, with the collaborative approach to caring for older patients in Islington resulting in staff having had the opportunity to build better relationships with their patients and understand their individual needs to a greater extent.