Our Integrated Case Management Team can help practices to manage patients who have complex and chaotic lives, which leads to an impact on their health.
They also help with patients who use appointments for non-health issues.
For the past year, the team has consisted of two nurses and an occupational therapy lead, but is about to more than double in size, with another two occupational therapists and two community social prescribers joining by the end of April 2021.
What can the team help with?
Patients who are not taking medicines as prescribed.- Those who are not engaging with the help they are being offered.
- Issues of loneliness/isolation.
- Self-neglect.
- High intensity users of health services.
- Complex social issues, which might include housing, finances and risk assessment.
- Complex and longstanding problems that have not been resolved.
Eligible patients include:
- Patients aged over 18 with complex multiple morbidities.
- Patients not requiring GP care but may have social care needs.
- Patients who are socially isolated and not engaging with services, which is having a negative impact on their health and wellbeing.
- Patients with non-clinical needs that require intervention to prevent escalation to providers in the wider health system.
How does the service work?
The team will contact patients within 48 hours and agree an initial plan.
They will also support frailty and community teams to manage complex non-medical problems which need complex onward referral and monitoring of interventions.
The team will not have a caseload but will aim to see, review and then discharge patients once interventions have been implemented. They will see patients again, if further support or management is needed.
This service is not for urgent referrals, which should continue to be accessed via the Acute Response Team (ART) and the Integrated Care Team (ICT).
Four sacks full of unused medication were taken from a home, when an Integrated Care Management (ICM) team visited a patient who told his GP that his tablets were not working.
Kent Community Health NHS Foundation Trust community nurses, who were treating Bill (not his real name) at home for wound care, raised concern, after seeing many packets of unopened medication in his bedroom.
He was referred to the (ICM) service which KCHFT provides to the Coastal and Rural East (CARE) Primary Care Network. Occupational Therapist Clinical Lead Anna Williams visited the patient and spent two afternoons with him, to try to discover why he wasn’t using what had been prescribed. Spending time with him – and by speaking with other professionals involved in his care – she was able to establish his reasons and put an action plan into place to help.
Anna spoke with the man’s GP and pharmacist, to stop further repeat prescriptions, which were not being used. She organised a medicines review and is in regular contact with the man’s GP, a pharmacist and other professionals, to make sure he receives the support he needs.
She said: “Although this was an extreme case, we often find people are not taking their medications, stop taking them after a week, or are not taking them properly. But they don’t always tell their GP. We find out the reasons why someone might be noncompliant with medications and we provide support. It’s just one of the many things we can help with.
“We talk to everyone involved, so in this case the patient, the GP, the pharmacist, the community nurses and other agencies, to get the full picture.”
The ICM team take part in a weekly multi-disciplinary team (MDT) meeting which brings partner organisations together. There is often more than one agency involved in a patient’s care. Meetings can involve KCHFT community nurses, the Acute Response Team (ART) in Thanet, social services, mental health, a care home co-ordinator, a geriatrician and a hospital frailty team, as well as representatives from housing associations and the voluntary sector, such as Age UK or Carers Support.
Referrals to the ICM team are made by GPs within the PCN, surgery receptionists, members of the MDT team and other health professionals. Patients can be seen in their own homes, or at a GP surgery.
Anna said: “Sometimes there are lots of agencies involved in a patient’s care. Our role is to facilitate meetings, to get all the professionals together, see that actions are followed up and to make sure we are all working closely together.
“The benefits to PCNs and GPs of having this service, is that it frees up GP and other service provision time and results in co-ordinated and integrated care.