Integrated Case Management
Dr Iolanthe Fowler
Hallam and South Locality (HASL) ICMT Sheffield November 2014-September 2015
Hallam and South G.P. Locality (representing 26 practices) developed an innovative, integrated team approach to the management of patients with complex health and social care needs.
2 teams were established, each to run weekly, covering all 26 practices in HASL. The aims of the ICMT were originally:
- To develop efficient MDT working and form links between social care and health
- To support patients better by responding in an agile and efficient way to needs identified
The scheme was advertised at GPA meetings and larger locality meetings, and notices and fliers were sent to practices. ICMT team members visited practices and talked directly to professionals about the ICMT.
Regular attendance was established from:
- Community nursing plus students
- SW team plus students
- Housing officers
- Pharmacy technicians
- Community Support Workers (local government employees)
and a senior business support officer was recruited to help manage the referral process and provide general administrative support the to team. Each team had a GP chair for their meeting and for clinical support and advice.
Referrals were made by email or telephone to the business support officer, from any professional with concerns about the person being referred.
Details required were kept intentionally brief: name, date of birth, address and contact details, the professional's concerns and any other relevant details e.g. next of kin or carer’s contact details. The aim was to keep the referral process as simple as possible for the referrer, and avoid form filling at the point of referral.
Reported learning from the project which could help to shape the future direction of integrated working included:
- The established links between team members were found to facilitate integrated working outside the MDT; MDT members reported that “the system” felt easier to navigate
- ICMT can be a point of contact/ entry for services outside primary care to access Primary care.
- Strong links can be formed between health and social care, and third sector organisations. Several charities attended ICMT, and regular referrals to third sector were made from ICMT with positive reported outcomes.
- “Sharing intelligence” across disciplines can allow work to be dealt with in a proactive way, pre-empting some crises’ and facilitating swift action when difficult situations did occur, we can reduce footfall through patient’s houses
- Many cases referred had mental health/substance misuse problems. A representative from local mental health services would have been beneficial.
- Communication between GP practices and ICMT can present challenges
- Practices prefer information via different routes e.g. email/ fax/ telephone call
- Knowing communication preferences can help effective communication
- Access to the GP computer systems for the GP chair, care coordinator and business support officer can facilitate communication between Practices and ICMT personnel, allowing immediate feedback from ICMT
- Referrals may come from professionals outside the G.P. practice (a call to the practice to inform that a patient has been referred prior to ICMT can inform practice staff of concerns of which they might be unaware, it can give an opportunity for contribution by GPs and practice staff to the information gathering exercise, and it can also allow invitation of practice staff to the ICMT meeting, which may help in the individual case and promote and demystify ICMT)
- Joint access to social care and health care records can be problematic. Possible solutions include:
- Mobile SW access to the social care records on site at GP surgeries
- GP chair/ Community nursing/ MOT pharmacists accessing the health records
- Consider the most efficient way to obtaining consent from patients for record sharing (between practices/ social care and the ICMT team) and enabling ICMT to access to GP patient records
An example of case referred to ICMT
Family C well known to all services, and well known that their house was in a terrible state. This became more of a problem as the health of one family member deteriorated and required home care, but the house being in such a poor state had caused carer agencies to refuse to go in. Working with housing and the third sector the house was decluttered and a deep clean arranged, which facilitated the re-instigation of care.
The ICMT facilitates multidisciplinary working through sharing professional intelligence, having a good skill mix, joint visiting and access to team members through the week which supports the weekly meetings. In meetings, professionals decide together, taking the service user/ carers’ wishes into consideration, the best unified approach to the provision of care and support. In HASL this approach has led to a notable reduction in the need for cross discipline phone calls, referral forms and has reduced the following problems:
- Not being able to speak to the right person at the right time
- Multiple failed contacts
- Multiple professionals involvement/ unnecessary footfall in patient’s houses
- Not knowing what has happened to your messages
- Not knowing what the actions have been
- Not knowing how the patient is
- Not knowing what YOU as a professional need to do next to best help your patient with complex health and social care needs
Being part of a team delivering care in this way is immensely satisfying. It may offer those who wish to embrace this way of working improved morale, with possible recruitment and retention benefits. The wider teams can benefit from access to a streamlined and coordinated process, which may reduce episodes of crisis presenting to the practice team.
ICMT deals with existing workload in a different way. This fresh approach is more proactive than reactive, and this logically reduces crises and distress to patients their families and carers and to professionals in caring roles. There can be an emphasis on holistic self-care and enablement, care planning and the potential to reduce acute hospital admissions, by providing the right care, at the right time, by the right team.